Provider Demographics
NPI:1700859865
Name:WONG, ROBERTSON (DPT)
Entity Type:Individual
Prefix:MR
First Name:ROBERTSON
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:DPT
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 120
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98231-0120
Mailing Address - Country:US
Mailing Address - Phone:360-332-8167
Mailing Address - Fax:360-332-0931
Practice Address - Street 1:250 G ST
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-4019
Practice Address - Country:US
Practice Address - Phone:360-332-8167
Practice Address - Fax:360-332-0931
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009206174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB19949Medicare ID - Type Unspecified