Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207VF0040X | Female Pelvic Medicine and Reconstructive Surgeon | 48640 | AZ |
NPI | 1639321284 |
---|---|
Provider Name | Keri S. Wong |
First Address | Litchfield Park, AZ 85340-9428 |
Second Address | Litchfield Park, AZ 85340-9428 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/10/2008 |
Last Update Date | 09/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P01197934 | RR MEDICARE (01) | MN |