MEDICARE: MS. JULIE WONG PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	PT10167	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ29485Z	OTHER	CA	BLUESHIELDPROVIDER #

General Provider Information

NPI Number	:	1003850629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JULIE WONG PT

Provider Business Mailing Address
First Line	:	1489 WEBSTER ST
Second Line	:	SUITE 210
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115-3766
Country	:	US
Telephone Number	:	415-346-8373
Fax Number	:

Provider Business Practice Location Address
First Line	:	1489 WEBSTER ST. SUITE 210
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94115
Country	:	US
Telephone Number	:	415-346-8373
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	03/17/2008

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