Provider Demographics
NPI:1447341904
Name:WONG, SANDRA LYNN (MD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
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 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:DEPT OF SURGERY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-1000
Mailing Address - Country:US
Mailing Address - Phone:603-650-5211
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:DEPT OF SURGERY
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-5211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH173902086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4761460Medicaid
MI4761460Medicaid
MI0H16112116Medicare ID - Type Unspecified