Provider Demographics
NPI:1609830504
Name:TONGCO, WAYNE P (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:P
Last Name:TONGCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 KNOB CREEK RD
Mailing Address - Street 2:SUITE 720
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2100
Mailing Address - Country:US
Mailing Address - Phone:423-926-6112
Mailing Address - Fax:423-434-0278
Practice Address - Street 1:2340 KNOB CREEK RD
Practice Address - Street 2:SUITE 720
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2100
Practice Address - Country:US
Practice Address - Phone:423-926-6112
Practice Address - Fax:423-434-0278
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD36058208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3875502Medicaid
TN3875502Medicare ID - Type Unspecified
TN3875502Medicaid