Healthcare Provider Details

I. General information

NPI: 1295917342
Provider Name (Legal Business Name): JANE P WONG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 11/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N. PEPPER AVE SURGERY DEPT 6TH FLOOR
COLTON CA
92324
US

IV. Provider business mailing address

1241E DYER RD
SANTA ANA CA
92705-5611
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-6210
  • Fax: 909-580-1363
Mailing address:
  • Phone: 714-978-4532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19420
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19420
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA19420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: