Healthcare Provider Details

I. General information

NPI: 1356305890
Provider Name (Legal Business Name): CHRISTABELLE N WONG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 E RIGGS RD SUITE 12-268
CHANDLER AZ
85249-4260
US

IV. Provider business mailing address

975 E RIGGS RD SUITE 12-268
CHANDLER AZ
85249-4260
US

V. Phone/Fax

Practice location:
  • Phone: 480-634-5521
  • Fax: 480-248-9011
Mailing address:
  • Phone: 480-634-5521
  • Fax: 480-248-9011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2725
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier872889
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer
# 2
Identifier3Z0050
Identifier TypeOTHER
Identifier StateAZ
Identifier IssuerHEALTHNET OF AZ
# 3
IdentifierP00386339
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: