=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487365938
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADFORD WONG PT, MPA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2022
-----------------------------------------------------
Last Update Date | 12/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 ALEGRE CT
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94526-4909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-552-0268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 ALEGRE CT
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94526-4909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-552-0268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT17401
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------