Provider Demographics
NPI:1366509572
Name:WONG, MICHAEL (PT)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 E LAS TUNAS DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1411
Mailing Address - Country:US
Mailing Address - Phone:626-451-0167
Mailing Address - Fax:
Practice Address - Street 1:206 E LAS TUNAS DR
Practice Address - Street 2:SUITE 5
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1411
Practice Address - Country:US
Practice Address - Phone:626-451-0167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT20628225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT20628AMedicare PIN