Provider Demographics
NPI:1962495044
Name:WONG, DEBRAH A (FNP)
Entity Type:Individual
Prefix:
First Name:DEBRAH
Middle Name:A
Last Name:WONG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SE SANDY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1308
Mailing Address - Country:US
Mailing Address - Phone:503-963-2846
Mailing Address - Fax:503-963-9505
Practice Address - Street 1:1111 NE 99TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-9428
Practice Address - Country:US
Practice Address - Phone:503-963-3030
Practice Address - Fax:503-963-3005
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR097006867N1 FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9643966Medicaid
OR276692Medicaid
WA9643966Medicaid
OR276692Medicaid