Provider Demographics
NPI:1134814429
Name:WONG, NICOLE (DO)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 STARFIRE WAY
Mailing Address - Street 2:
Mailing Address - City:GOLDEN
Mailing Address - State:CO
Mailing Address - Zip Code:80401-8847
Mailing Address - Country:US
Mailing Address - Phone:651-503-2610
Mailing Address - Fax:
Practice Address - Street 1:965 WILSON RD RM A327
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-6410
Practice Address - Country:US
Practice Address - Phone:517-353-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program