Basic Information
| Provider Information | |||||||||
| NPI: | 1114073277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 94-1480 MOANIANI ST | ||||||||
| Address2: | |||||||||
| City: | WAIPAHU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967974632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084323100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 94-1480 MOANIANI ST | ||||||||
| Address2: | |||||||||
| City: | WAIPAHU | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967974632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8084323100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 10/19/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD-2899 | HI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 040919-02 | 05 | HI | MEDICAID |