Healthcare Provider Details

I. General information

NPI: 1124474960
Provider Name (Legal Business Name): BRIAN WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 W BAVARIA ST
EAGLE ID
83616-5171
US

IV. Provider business mailing address

PO BOX 190930
BOISE ID
83719-0930
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-6200
  • Fax: 208-302-6245
Mailing address:
  • Phone: 208-367-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-14689
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: