Healthcare Provider Details

I. General information

NPI: 1619138310
Provider Name (Legal Business Name): NANCY WONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 MEDICAL CENTER PT STE 220
COLORADO SPRINGS CO
80907
US

IV. Provider business mailing address

1625 MEDICAL CENTER PT STE 220
COLORADO SPRINGS CO
80907-5798
US

V. Phone/Fax

Practice location:
  • Phone: 719-364-5080
  • Fax: 719-364-5081
Mailing address:
  • Phone: 719-364-5080
  • Fax: 719-364-5081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberQ0847
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLL1855
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberDR.0060735
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: