MEDICARE: CAROLE GOLES WONG PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT60060980	WA

General Provider Information

NPI Number	:	1669614004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLE GOLES WONG PT

Provider Business Mailing Address
First Line	:	410 W POPLAR ST.
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-1796
Country	:	US
Telephone Number	:	509-897-3320
Fax Number	:	509-897-5752

Provider Business Practice Location Address
First Line	:	410 W POPLAR ST.
Second Line	:
City	:	WALLA WALLA
State	:	WA
Zip	:	99362-1796
Country	:	US
Telephone Number	:	509-897-2100
Fax Number	:	509-897-5752

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2009
Last Update Date	:	02/02/2017

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