Healthcare Provider Details

I. General information

NPI: 1841815883
Provider Name (Legal Business Name): ALEX WANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2020
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14410 SE PETROVITSKY RD STE 104
RENTON WA
98058-8900
US

IV. Provider business mailing address

14410 SE PETROVITSKY RD STE 104
RENTON WA
98058-8900
US

V. Phone/Fax

Practice location:
  • Phone: 425-690-3405
  • Fax:
Mailing address:
  • Phone: 425-690-3405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD61519863
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: