Provider Demographics
NPI:1063677755
Name:KONG, AMANDA L (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:L
Last Name:KONG
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:SURGICAL ONCOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-5020
Mailing Address - Fax:414-805-5771
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:SURGICAL ONCOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-5020
Practice Address - Fax:414-805-5771
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2012-01-18
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Provider Licenses
StateLicense IDTaxonomies
WI51977208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063677755Medicaid
WI736011251Medicare PIN