Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0210X | Pediatric Nephrologist | 2000-318 | NM |
NPI | 1669489613 |
---|---|
Provider Name | Craig Wong |
First Address | Albuquerque, NM 87131-0001 |
Second Address | Albuquerque, NM 87131-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2006 |
Last Update Date | 18/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G-79310 | (02) | NM |