Provider Demographics
NPI:1366516205
Name:WONG, IRENE SHUK (NP)
Entity type:Individual
Prefix:MISS
First Name:IRENE
Middle Name:SHUK
Last Name:WONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:SHUK
Other - Middle Name:L
Other - Last Name:WONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:12900 PARK PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:562-622-2800
Mailing Address - Fax:
Practice Address - Street 1:4855 ATHERTON AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95130
Practice Address - Country:US
Practice Address - Phone:888-357-3058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12816363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ15459Medicare UPIN