Provider Demographics
NPI:1194404632
Name:WONG, BRANDON (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 HUNTINGTON DR # 104
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-2640
Mailing Address - Country:US
Mailing Address - Phone:626-731-0152
Mailing Address - Fax:
Practice Address - Street 1:351 PARK SHADOW CT
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3295
Practice Address - Country:US
Practice Address - Phone:626-731-0152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant