Provider Demographics
NPI:1043290703
Name:WONG, SO-FONG (FNP, CNS, CDE)
Entity Type:Individual
Prefix:MS
First Name:SO-FONG
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:FNP, CNS, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 CRENSHAW RD
Mailing Address - Street 2:STE 100
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3138
Mailing Address - Country:US
Mailing Address - Phone:281-487-1000
Mailing Address - Fax:832-399-4110
Practice Address - Street 1:5050 CRENSHAW RD
Practice Address - Street 2:STE 100
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3138
Practice Address - Country:US
Practice Address - Phone:281-487-1000
Practice Address - Fax:832-399-4110
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21210407163WD0400X
TXAP110586364SA2200X, 363LF0000X
TX654824363LF0000X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN8558OtherPTAN
093873001OtherTPI
093873001OtherTPI
TXQ37070Medicare UPIN
TX8D2818Medicare ID - Type UnspecifiedNURSE PRACTITIONER
TX260959YLLWMedicare PIN
TX176238702Medicaid
TXP01136130OtherRAILROAD MEDICARE
TX893N78OtherBCBSTX