Provider Demographics
NPI:1992192579
Name:KIM, AMANDA JANE WONG (MD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE WONG
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3915 TALBOT RD S STE 401
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5738
Mailing Address - Country:US
Mailing Address - Phone:425-690-3445
Mailing Address - Fax:
Practice Address - Street 1:3915 TALBOT RD S STE 401
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5738
Practice Address - Country:US
Practice Address - Phone:425-690-3445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA144999207Q00000X
WAMD60845015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program