Provider Demographics
NPI:1336352335
Name:WONG, EDMUND H (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:H
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 1:1304 FAWCETT AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1911
Mailing Address - Country:US
Mailing Address - Phone:253-680-3555
Mailing Address - Fax:
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-680-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD602463592085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8905842Medicare PIN
WAG8905846Medicare PIN
ORR171479Medicare PIN