Provider Demographics
NPI:1053367144
Name:WONG, CARRIE CHARLENE (MD)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:CHARLENE
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:WONG
Other - Last Name:BERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 5299
Mailing Address - Street 2:MS: 737-3-PCON
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2202 SOUTH CEDAR ST #300/#200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-301-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039643207VB0002X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VB0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0149432OtherL & I PROVIDER NUMBER
WA7029452OtherAETNA PROVIDER NUMBER
WA91120349475OtherKPS PROVIDER NUMBER
WA6688WOOtherREGENCE RIDER NUMBER
WA8276735Medicaid
WA98372D006OtherTRICARE PROVIDER NUMBER
WA8276735Medicaid