Basic Information
| Provider Information | |||||||||
| NPI: | 1811453582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | KIT | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9040 JACKSON AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682462 | ||||||||
| FaxNumber: | 2539682972 | ||||||||
| Practice Location | |||||||||
| Address1: | 36065 SANTA FE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT HOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765445060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542888000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2019 | ||||||||
| LastUpdateDate: | 07/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 75070-21 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 75070-21 | WI | N | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.