Provider Demographics
NPI:1972577500
Name:WONG, HEATHER GAGNON (MS PT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:GAGNON
Last Name:WONG
Suffix:
Gender:F
Credentials:MS PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8340 LINDEN LANE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66207
Mailing Address - Country:US
Mailing Address - Phone:913-707-4303
Mailing Address - Fax:
Practice Address - Street 1:8340 LINDEN LANE
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66207
Practice Address - Country:US
Practice Address - Phone:913-707-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119884225100000X
KS11-02753225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO484700406Medicaid