Provider Demographics
NPI:1457557043
Name:WING, JILL O (PA-C)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:O
Last Name:WING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JILL
Other - Middle Name:O
Other - Last Name:HONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9961 SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:909-427-5412
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-5412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA17985CMedicare PIN
CAWPA17985AMedicare PIN
CAWPA17985BMedicare PIN