Provider Demographics
NPI:1043540800
Name:WONG, SHAMROCK (RD)
Entity Type:Individual
Prefix:MS
First Name:SHAMROCK
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 MOUNTFORD DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-5246
Mailing Address - Country:US
Mailing Address - Phone:408-893-4115
Mailing Address - Fax:408-629-7329
Practice Address - Street 1:6315 MOUNTFORD DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95123-5246
Practice Address - Country:US
Practice Address - Phone:408-893-4115
Practice Address - Fax:408-629-7329
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA960957133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered