Healthcare Provider Details

I. General information

NPI: 1083508055
Provider Name (Legal Business Name): KRISTIN GRACE WONG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20920 CHICO ST
CARSON CA
90746-3603
US

IV. Provider business mailing address

27930 RIDGEBROOK CT
RANCHO PALOS VERDES CA
90275-3303
US

V. Phone/Fax

Practice location:
  • Phone: 888-530-4415
  • Fax: 833-973-3630
Mailing address:
  • Phone: 310-863-8236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: