Healthcare Provider Details

I. General information

NPI: 1386919686
Provider Name (Legal Business Name): DAVID SAMUEL WENGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 08/27/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 NE 130TH LN STE 550
KIRKLAND WA
98034-3041
US

IV. Provider business mailing address

12303 NE 130TH LN STE 550
KIRKLAND WA
98034-3041
US

V. Phone/Fax

Practice location:
  • Phone: 425-899-6972
  • Fax: 425-899-6970
Mailing address:
  • Phone: 425-899-6972
  • Fax: 425-899-6970

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberML 60285219
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.MD.60481954
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: