Healthcare Provider Details

I. General information

NPI: 1447712906
Provider Name (Legal Business Name): CARMEN W WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 ROWLAND WAY STE 206
NOVATO CA
94945-5055
US

IV. Provider business mailing address

165 ROWLAND WAY STE 206
NOVATO CA
94945-5055
US

V. Phone/Fax

Practice location:
  • Phone: 415-898-9818
  • Fax: 415-892-3475
Mailing address:
  • Phone: 415-898-9818
  • Fax: 415-892-3475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5865
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: