Healthcare Provider Details

I. General information

NPI: 1376170449
Provider Name (Legal Business Name): JASON PATRICK WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 THE CITY DR S STE 400
ORANGE CA
92868-3201
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5636
  • Fax:
Mailing address:
  • Phone: 714-456-5691
  • Fax: 714-456-8874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA183678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: