Provider Demographics
NPI:1861065831
Name:HOANG, KHA (MA61112149)
Entity type:Individual
Prefix:
First Name:KHA
Middle Name:
Last Name:HOANG
Suffix:
Gender:M
Credentials:MA61112149
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 SYCAMORE ST SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-3338
Mailing Address - Country:US
Mailing Address - Phone:360-878-5726
Mailing Address - Fax:
Practice Address - Street 1:1412 E YELM AVE STE C101
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-8328
Practice Address - Country:US
Practice Address - Phone:360-458-7533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61112149225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist