Provider Demographics
NPI:1619389863
Name:WONG, ANDREW (LAC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 112TH AVE NE STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-2945
Mailing Address - Country:US
Mailing Address - Phone:347-683-2549
Mailing Address - Fax:
Practice Address - Street 1:2105 112TH AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-2945
Practice Address - Country:US
Practice Address - Phone:347-683-2549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC61104893171100000X
NY005321171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist