Healthcare Provider Details

I. General information

NPI: 1134814429
Provider Name (Legal Business Name): NICOLE WONG DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 E SHERMAN BLVD STE 2400
MUSKEGON MI
49444-1886
US

IV. Provider business mailing address

2555 W RIVER RD
MUSKEGON MI
49445-9701
US

V. Phone/Fax

Practice location:
  • Phone: 231-672-4243
  • Fax:
Mailing address:
  • Phone: 651-503-2610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number5101029594
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: