Provider Demographics
NPI:1508054826
Name:WONG, SAN SOPHIE
Entity Type:Individual
Prefix:DR
First Name:SAN
Middle Name:SOPHIE
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SAN
Other - Middle Name:MYINT
Other - Last Name:MA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:1330 ROCKEFELLER AVE
Practice Address - Street 2:SUITE 520
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1684
Practice Address - Country:US
Practice Address - Phone:425-261-4905
Practice Address - Fax:425-261-4945
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60206188207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60206188OtherWSL
WAMD60206188OtherWSL