Provider Demographics
NPI:1932314374
Name:WONGBA, WARANGKHANA (MD)
Entity Type:Individual
Prefix:
First Name:WARANGKHANA
Middle Name:
Last Name:WONGBA
Suffix:
Gender:F
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 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:
Mailing Address - Fax:
Practice Address - Street 1:500 LILLY RD NE STE 201
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5197
Practice Address - Country:US
Practice Address - Phone:360-413-8272
Practice Address - Fax:360-413-8878
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60649849207R00000X, 207RC0200X, 207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301097582OtherMI MEDICAL LICENSE
12016698OtherAAMC ID
0-647-9646OtherUSMLE AND ECFMG ID
IL125-048864OtherLICENSED MEDICAL TEMPORAR
IA39830OtherIA MEDICAL LICENSE