Provider Demographics
NPI:1497307763
Name:WONG, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 BUENAVENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-3700
Mailing Address - Country:US
Mailing Address - Phone:530-225-8500
Mailing Address - Fax:
Practice Address - Street 1:1842 BUENAVENTURA BLVD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-3700
Practice Address - Country:US
Practice Address - Phone:530-225-8500
Practice Address - Fax:530-246-4000
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2388363A00000X
CAPA59545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA59545OtherCALIFORNIA PA LICENSE
NVPA2388OtherNEVADA PA LICENSE