Provider Demographics
NPI:1194416826
Name:WONG, RYAN ENOCH (PT, DPT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ENOCH
Last Name:WONG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 E IMPERIAL HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6735
Mailing Address - Country:US
Mailing Address - Phone:714-988-8110
Mailing Address - Fax:714-988-8111
Practice Address - Street 1:32 DISCOVERY
Practice Address - Street 2:STE 100
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618
Practice Address - Country:US
Practice Address - Phone:949-271-0010
Practice Address - Fax:714-256-0770
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303935225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist