Provider Demographics
NPI:1053445270
Name:WONG, LARA LYN AN (MD)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:LYN AN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 PUNCHBOWL ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2402
Mailing Address - Country:US
Mailing Address - Phone:808-691-4970
Mailing Address - Fax:808-691-5302
Practice Address - Street 1:1301 PUNCHBOWL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2402
Practice Address - Country:US
Practice Address - Phone:808-691-4970
Practice Address - Fax:808-691-5302
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83346207RE0101X
HIMD-21517207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI003855Medicaid