Healthcare Provider Details

I. General information

NPI: 1831219344
Provider Name (Legal Business Name): HARLAND WONG OPAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 OCONNOR DR SUITE 310 B
SAN JOSE CA
95128-1633
US

IV. Provider business mailing address

455 OCONNOR DR SUITE 310 B
SAN JOSE CA
95128-1633
US

V. Phone/Fax

Practice location:
  • Phone: 408-297-2833
  • Fax: 408-271-4908
Mailing address:
  • Phone: 408-297-2833
  • Fax: 408-271-4908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number199
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: