Provider Demographics
NPI:1104839562
Name:WONG, SANDRA K (MPT)
Entity type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:K
Last Name:WONG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GAUGUIN CIR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3876
Mailing Address - Country:US
Mailing Address - Phone:949-702-3992
Mailing Address - Fax:949-481-2891
Practice Address - Street 1:101 GAUGUIN CIR
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3876
Practice Address - Country:US
Practice Address - Phone:949-702-3992
Practice Address - Fax:949-481-2891
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27363225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT27363Medicare ID - Type UnspecifiedPHYSICAL THERAPIST