Provider Demographics
NPI:1427329457
Name:WONG, ELISE MEGAN (ND, LAC)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:MEGAN
Last Name:WONG
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 SE ALDER ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2400
Mailing Address - Country:US
Mailing Address - Phone:503-477-5051
Mailing Address - Fax:503-477-5051
Practice Address - Street 1:1110 SE ALDER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2400
Practice Address - Country:US
Practice Address - Phone:503-477-5051
Practice Address - Fax:503-477-5051
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1870175F00000X
ORAC156030171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist