MEDICARE: MISS STACY TENNILLE WONG CRNA

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	367500000X	Certified Registered Nurse Anesthetist	95002044	CA
2	163W00000X	Registered Nurse	762032	CA
3	367500000X	Certified Registered Nurse Anesthetist	CRNA95002044	CA
4	163WC0200X	Critical Care Medicine Registered Nurse	730127-1	NY

General Provider Information

NPI Number	:	1063908317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS STACY TENNILLE WONG CRNA

Provider Business Mailing Address
First Line	:	300 PASTEUR DR
Second Line	:
City	:	STANFORD
State	:	CA
Zip	:	94305-2200
Country	:	US
Telephone Number	:	650-723-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	521 PARNASSUS AVE
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94143-2206
Country	:	US
Telephone Number	:	415-514-3785
Fax Number	:	415-476-9516

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

Provider Enumeration Date	:	07/10/2018
Last Update Date	:	06/15/2026

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