Provider Demographics
NPI:1437102100
Name:WONG, ELIZABETH (C R N A)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:C R N A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 KIRSTEN LEE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91361
Mailing Address - Country:US
Mailing Address - Phone:818-707-1623
Mailing Address - Fax:818-707-1623
Practice Address - Street 1:435 N ROXBURY DR
Practice Address - Street 2:104
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210
Practice Address - Country:US
Practice Address - Phone:310-278-1839
Practice Address - Fax:310-278-4320
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA2435367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP78752Medicare UPIN
CAWNA2435CMedicare ID - Type Unspecified