Provider Demographics
NPI:1376779520
Name:WONG, REGAN (PT)
Entity Type:Individual
Prefix:
First Name:REGAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W MAYFIELD RD STE 116
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2084
Mailing Address - Country:US
Mailing Address - Phone:972-623-2629
Mailing Address - Fax:972-623-2661
Practice Address - Street 1:515 W MAYFIELD RD STE 116
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2084
Practice Address - Country:US
Practice Address - Phone:972-623-2629
Practice Address - Fax:972-623-2661
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11630132081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine