Provider Demographics
NPI:1336525609
Name:WONG, MICHELLE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:WONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANN
Other - Last Name:AUSILIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST STE 900
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:200 MISSION BLVD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2564
Practice Address - Country:US
Practice Address - Phone:209-223-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant