Healthcare Provider Details

I. General information

NPI: 1811663594
Provider Name (Legal Business Name): CRESTLEY PATRICIA WONG OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2021
Last Update Date: 08/21/2021
Certification Date: 08/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N CORONADO DR STE A
SIERRA VISTA AZ
85635-6359
US

IV. Provider business mailing address

9652 HOLLY CREEK CT
ELK GROVE CA
95757-8309
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-1529
  • Fax:
Mailing address:
  • Phone: 916-833-4748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34923
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: