Healthcare Provider Details

I. General information

NPI: 1134353949
Provider Name (Legal Business Name): PRISCILLA H WONG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2009
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 E ROSEVILLE PKWY STE 110
ROSEVILLE CA
95661-3303
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 916-865-1092
  • Fax: 916-865-1097
Mailing address:
  • Phone: 916-865-1092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA159362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: