Provider Demographics
NPI:1316930985
Name:HOANG, KHANH BAO (DPM)
Entity type:Individual
Prefix:DR
First Name:KHANH
Middle Name:BAO
Last Name:HOANG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:DR
Other - First Name:CONNIE
Other - Middle Name:BAO
Other - Last Name:HOANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:3901 NORTHRIDGE PL SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-7187
Mailing Address - Country:US
Mailing Address - Phone:360-402-1015
Mailing Address - Fax:
Practice Address - Street 1:3901 NORTHRIDGE PL SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-7187
Practice Address - Country:US
Practice Address - Phone:360-402-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO 00000794213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery