Provider Demographics
NPI:1194991901
Name:AN, FREDRICK SUNGJAE (DO)
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:SUNGJAE
Last Name:AN
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5166
Mailing Address - Country:US
Mailing Address - Phone:360-491-9480
Mailing Address - Fax:360-456-2413
Practice Address - Street 1:413 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5166
Practice Address - Country:US
Practice Address - Phone:360-491-9480
Practice Address - Fax:360-456-2413
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO29350207R00000X
WAOP61580368208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2013154Medicaid