Provider Demographics
NPI:1558894741
Name:WONG, LAI MAN
Entity Type:Individual
Prefix:
First Name:LAI MAN
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 1:1927 HARBOR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-7602
Mailing Address - Country:US
Mailing Address - Phone:360-474-3511
Mailing Address - Fax:
Practice Address - Street 1:150 PAULARINO AVE STE 182
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3301
Practice Address - Country:US
Practice Address - Phone:800-482-5174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006175363LF0000X
WAAP60746640363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8967989OtherMEDICARE