Provider Demographics
NPI:1114334950
Name:KWONG, MELODY HOI-WAH (PA-C)
Entity Type:Individual
Prefix:
First Name:MELODY
Middle Name:HOI-WAH
Last Name:KWONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELODY
Other - Middle Name:HOI-WAH
Other - Last Name:SO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:800 N TUSTIN AVE
Mailing Address - Street 2:STE G
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3605
Mailing Address - Country:US
Mailing Address - Phone:714-547-6111
Mailing Address - Fax:714-547-0833
Practice Address - Street 1:25455 MEDICAL CENTER DR
Practice Address - Street 2:SUITE #200
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5963
Practice Address - Country:US
Practice Address - Phone:951-894-7056
Practice Address - Fax:951-894-2702
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant