Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 111200 | MO |
Y | 2084N0402X | Child Neurologist | 111200 | MO |
N | 2084N0600X | Clinical Neurophysiologist | 111200 | MO |
NPI | 1053338590 |
---|---|
Provider Name | Dr. Michael Wong |
First Address | Saint Louis, MO 63110-1010 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
205453202 | (05) | MO |