Provider Demographics
NPI:1992796650
Name:YI, IM S (MD)
Entity type:Individual
Prefix:
First Name:IM
Middle Name:S
Last Name:YI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26004 104TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7677
Mailing Address - Country:US
Mailing Address - Phone:425-251-4040
Mailing Address - Fax:
Practice Address - Street 1:26004 104TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7677
Practice Address - Country:US
Practice Address - Phone:425-251-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055784207Q00000X
WAMD00047267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8497141Medicaid
IN000000373612OtherANTHEM
INH79017Medicare UPIN
IN000000373612OtherANTHEM
IN227540CMedicare ID - Type Unspecified
WAG8869011Medicare PIN