Healthcare Provider Details

I. General information

NPI: 1376403121
Provider Name (Legal Business Name): TAYLOR WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 FLORIDA AVE
MODESTO CA
95350-4418
US

IV. Provider business mailing address

5323 HARRY HINES BLVD STOP 7200
DALLAS TX
75390-9090
US

V. Phone/Fax

Practice location:
  • Phone: 209-578-1211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: