Provider Demographics
NPI:1861615957
Name:WONG, EDWIN (LAC)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 W 45TH AVE
Mailing Address - Street 2:B
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109
Mailing Address - Country:US
Mailing Address - Phone:806-352-0225
Mailing Address - Fax:
Practice Address - Street 1:6015 W 45TH AVE
Practice Address - Street 2:#B
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-5117
Practice Address - Country:US
Practice Address - Phone:806-352-0225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00190171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist