Provider Demographics
NPI:1104367846
Name:WONG, HEATHER (PAC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6690 LIMONITE FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509
Mailing Address - Country:US
Mailing Address - Phone:909-450-5200
Mailing Address - Fax:
Practice Address - Street 1:437 N EUCLID AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-3456
Practice Address - Country:US
Practice Address - Phone:909-988-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant