Provider Demographics
NPI:1124601950
Name:WONG, THEODORE ALAN (CRNA, RN)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:ALAN
Last Name:WONG
Suffix:
Gender:M
Credentials:CRNA, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 BRANNAN ST UNIT 677
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-5276
Mailing Address - Country:US
Mailing Address - Phone:256-527-1995
Mailing Address - Fax:
Practice Address - Street 1:1802 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1932
Practice Address - Country:US
Practice Address - Phone:205-934-3411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95238443163W00000X
AL134436367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse