Healthcare Provider Details

I. General information

NPI: 1679353064
Provider Name (Legal Business Name): ELSOM WONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 STRAKA TER
OKLAHOMA CITY OK
73139-2544
US

IV. Provider business mailing address

3000 N GRAND BLVD
OKLAHOMA CITY OK
73107-1818
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-6688
  • Fax:
Mailing address:
  • Phone: 405-632-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5052
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: