Healthcare Provider Details

I. General information

NPI: 1316206691
Provider Name (Legal Business Name): HUGH PHONG WONG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 N CARRIAGE PKWY
WICHITA KS
67208-4500
US

IV. Provider business mailing address

PO BOX 8035
WICHITA KS
67208-0035
US

V. Phone/Fax

Practice location:
  • Phone: 316-651-2250
  • Fax: 316-689-9391
Mailing address:
  • Phone: 316-689-9135
  • Fax: 316-689-9769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number04-39317
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301100415
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301100415
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: