Healthcare Provider Details

I. General information

NPI: 1477124717
Provider Name (Legal Business Name): TIFFANY WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2021
Last Update Date: 08/30/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 MARKET PL
SAN RAMON CA
94583-4745
US

IV. Provider business mailing address

PO BOX 333
MILLBRAE CA
94030-0333
US

V. Phone/Fax

Practice location:
  • Phone: 800-972-5547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95017439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: