Healthcare Provider Details

I. General information

NPI: 1437102100
Provider Name (Legal Business Name): ELIZABETH WONG C R N A
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N ROXBURY DR 104
BEVERLY HILLS CA
90210
US

IV. Provider business mailing address

2603 KIRSTEN LEE DRIVE
WEST LAKE VILLAGE CA
91361
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-1839
  • Fax: 310-278-4320
Mailing address:
  • Phone: 818-707-1623
  • Fax: 818-707-1623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA2435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: