Basic Information
| Provider Information | |||||||||
| NPI: | 1134214307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | UNIVERSITY OF MINNESOTA PHYSICIANS | ||||||||
| Address2: | 420 DELAWARE ST SE MMC 292 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122736004 | ||||||||
| FaxNumber: | 6122738459 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HARVARD STREET SE | ||||||||
| Address2: | UNIT J2-300 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122736004 | ||||||||
| FaxNumber: | 6122738459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 47826 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0144508 | 05 | MT | MEDICAID | 0594143 | 05 | IA | MEDICAID | 2366354 | 01 | MN | AMERICA'S PPO | OTHER | 615T6WO | 01 | MN | BCBS MN | OTHER | 208670100 | 05 | MN | MEDICAID | 132919 | 01 | MN | UCARE | OTHER | B632 | 01 | MN | CHAMPUS | OTHER | 34666400 | 05 | WI | MEDICAID | 238881 | 01 | MN | FAIRVIEW | OTHER | HP52811 | 01 | MN | HEALTHPARTNERS | OTHER | 16-02032 | 01 | MN | MEDICA PRIMARY | OTHER | 16-03682 | 01 | MN | MEDICA - CHOICE | OTHER | 1044141 | 01 | MN | PREFERREDONE | OTHER |