Provider Demographics
NPI:1861993586
Name:WONG, HARRY (PT, DPT)
Entity type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17100 NORTH 67TH AVE
Mailing Address - Street 2:BLD 1, SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-3612
Mailing Address - Country:US
Mailing Address - Phone:623-979-2747
Mailing Address - Fax:623-979-3122
Practice Address - Street 1:17100 NORTH 67TH AVE
Practice Address - Street 2:BLD 1, SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-3612
Practice Address - Country:US
Practice Address - Phone:623-979-2747
Practice Address - Fax:623-979-3122
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12227PT208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
86-0929640OtherTIN