Provider Demographics
NPI:1497531776
Name:WONG, MARLA
Entity Type:Individual
Prefix:
First Name:MARLA
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 1:1080 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-1924
Mailing Address - Country:US
Mailing Address - Phone:925-464-6987
Mailing Address - Fax:
Practice Address - Street 1:1080 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94556-1924
Practice Address - Country:US
Practice Address - Phone:925-464-6987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program