Provider Demographics
NPI:1235703463
Name:WONG, BRENT ARTHUR (DPT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ARTHUR
Last Name:WONG
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 233RD PL SW
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98021-7314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5620 RAINIER AVE S STE 102
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-2498
Practice Address - Country:US
Practice Address - Phone:206-535-8061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61155889225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist