Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YS0123X | Facial Plastic Surgeon | 14868 | OR |
NPI | 1497763932 |
---|---|
Provider Name | Tom D. Wang |
First Address | Portland, OR 97239-4501 |
Second Address | Portland, OR 97239-4501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2006 |
Last Update Date | 13/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
055868 | (05) | OR |
D81132 | (02) |