Provider Demographics
NPI:1619314796
Name:WONG, ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WONG
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:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:
Practice Address - Street 1:3477 S MERCY RD STE 201
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0448
Practice Address - Country:US
Practice Address - Phone:480-728-6580
Practice Address - Fax:480-728-6581
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ52842207Q00000X
KS9408168207Q00000X
KS04-38474207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619314796OtherNPI