Healthcare Provider Details

I. General information

NPI: 1629860143
Provider Name (Legal Business Name): VIVIAN WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GILMAN DR
LA JOLLA CA
92093-2442
US

IV. Provider business mailing address

9500 GILMAN DR
LA JOLLA CA
92093-5004
US

V. Phone/Fax

Practice location:
  • Phone: 858-534-0830
  • Fax:
Mailing address:
  • Phone: 858-534-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: