Provider Demographics
NPI:1558067025
Name:WONG, JUSTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 KAPIOLANI BLVD STE 705
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-5241
Mailing Address - Country:US
Mailing Address - Phone:808-295-5586
Mailing Address - Fax:
Practice Address - Street 1:1301 PUNCHBOWL ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2402
Practice Address - Country:US
Practice Address - Phone:808-295-5586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant