Healthcare Provider Details

I. General information

NPI: 1609432277
Provider Name (Legal Business Name): MECLENA ABIGAIL WONG PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ABIGAIL WONG PTA

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 05/19/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 S ELISEO DR
GREENBRAE CA
94904-2006
US

IV. Provider business mailing address

4560 SE INTERNATIONAL WAY STE 100
MILWAUKIE OR
97222-4628
US

V. Phone/Fax

Practice location:
  • Phone: 415-461-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number09740
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number50540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: