Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 125066452 | IL |
N | 207VG0400X | Gynecologist | MD204040 | OR |
NPI | 1043609712 |
---|---|
Provider Name | Dr. Jacqueline Mahn Kwan Wong |
First Address | Portland, OR 97239-3011 |
Second Address | Portland, OR 97239-3011 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2015 |
Last Update Date | 29/05/2021 |