Provider Demographics
NPI:1972724227
Name:WONG, BANNY SHING-CHI (MD)
Entity Type:Individual
Prefix:
First Name:BANNY
Middle Name:SHING-CHI
Last Name:WONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:501 SE 172ND AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-9542
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1712
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN49892207R00000X
ORMD158067207RG0100X
WAMD60623525207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1972724227Medicaid
MNP00839015OtherMEDICARE, RAILROAD
MNENROLLEDMedicaid
MNP00839015OtherMEDICARE, RAILROAD
WA1972724227Medicaid
ORP01179401Medicare PIN