Healthcare Provider Details

I. General information

NPI: 1346410883
Provider Name (Legal Business Name): NOUANSY KHOWONG WILTON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON
TACOMA WA
98431-1101
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-0208
  • Fax:
Mailing address:
  • Phone: 253-968-0208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number50523-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: