Basic Information
| Provider Information | |||||||||
| NPI: | 1972724227 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | BANNY | ||||||||
| MiddleName: | SHING-CHI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
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| Practice Location | |||||||||
| Address1: | 501 SE 172ND AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986849542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608822778 | ||||||||
| FaxNumber: | 3606041712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 03/16/2016 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 49892 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | MD158067 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | MD60623525 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1972724227 | 05 | WA | MEDICAID | P00839015 | 01 | MN | MEDICARE, RAILROAD | OTHER | ENROLLED | 05 | MN | MEDICAID |