Provider Demographics
NPI:1275846479
Name:WILSON, CHONG IM (LMP)
Entity Type:Individual
Prefix:
First Name:CHONG
Middle Name:IM
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6403 88TH STREET CT SW
Mailing Address - Street 2:APT 12
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-2695
Mailing Address - Country:US
Mailing Address - Phone:253-503-9527
Mailing Address - Fax:
Practice Address - Street 1:6403 88TH STREET CT SW
Practice Address - Street 2:APT 12
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2695
Practice Address - Country:US
Practice Address - Phone:253-503-9527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60116023172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist