Healthcare Provider Details

I. General information

NPI: 1588187546
Provider Name (Legal Business Name): MATTHEW K WONG RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2017
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 W SUNSET BLVD
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 650-520-6864
  • Fax:
Mailing address:
  • Phone: 650-520-6864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF382837
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number717958
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: