Provider Demographics
NPI:1801999818
Name:WONG, RENA SOPHIE (MD)
Entity type:Individual
Prefix:DR
First Name:RENA
Middle Name:SOPHIE
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17646 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98148-1729
Mailing Address - Country:US
Mailing Address - Phone:206-248-7282
Mailing Address - Fax:206-248-8143
Practice Address - Street 1:17646 1ST AVE S
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98148-1729
Practice Address - Country:US
Practice Address - Phone:206-248-7282
Practice Address - Fax:206-248-8143
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034086208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1100239Medicaid
WA1100239Medicaid