Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 1163013 | TX |
Y | 213ES0000X | Sports Medicine | 1163013 | TX |
NPI | 1376779520 |
---|---|
Provider Name | Regan Wong |
First Address | Arlington, TX 76014-2084 |
Second Address | Arlington, TX 76014-2084 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2009 |
Last Update Date | 16/02/2010 |