Provider Demographics
NPI:1366472649
Name:WONG, DOMINIC TAN (GNP-BC)
Entity Type:Individual
Prefix:MR
First Name:DOMINIC
Middle Name:TAN
Last Name:WONG
Suffix:
Gender:M
Credentials:GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15971 THOMPSON RANCH DRIVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91387
Mailing Address - Country:US
Mailing Address - Phone:818-288-2373
Mailing Address - Fax:661-251-1681
Practice Address - Street 1:13652 CANTARA ST
Practice Address - Street 2:BALBOA PLAZA BLDG
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5423
Practice Address - Country:US
Practice Address - Phone:818-832-7287
Practice Address - Fax:818-250-0061
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 587716163W00000X
CA587716163W00000X
CANP 15170163WG0600X
CA15170363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology