Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 3811 | OR |
N | 207R00000X | Internist | 3811 | OR |
N | 111NI0900X | Internist | 3811 | OR |
N | 111NS0005X | Chiropractic Sports Physician | 3811 | OR |
N | 111NX0100X | Occupational Health | 3811 | OR |
NPI | 1477794436 |
---|---|
Provider Name | Jonathan Wong |
First Address | Tualatin, OR 97062-8354 |
Second Address | Tualatin, OR 97062-8354 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2009 |
Last Update Date | 11/09/2018 |