Provider Demographics
NPI:1396095675
Name:WONG, KRISTEN MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:WONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1850 S AZUSA AVE
Mailing Address - Street 2:SUITE 88
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6813
Mailing Address - Country:US
Mailing Address - Phone:626-964-3040
Mailing Address - Fax:626-964-4720
Practice Address - Street 1:1850 S AZUSA AVE
Practice Address - Street 2:SUITE 88
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6813
Practice Address - Country:US
Practice Address - Phone:626-964-3040
Practice Address - Fax:626-964-4720
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant