Provider Demographics
NPI:1578585915
Name:WONG, PETRA A (MD)
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:A
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3801 KATELLA AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3372
Mailing Address - Country:US
Mailing Address - Phone:562-430-6472
Mailing Address - Fax:562-431-2975
Practice Address - Street 1:3801 KATELLA AVE STE 300
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3372
Practice Address - Country:US
Practice Address - Phone:562-430-6472
Practice Address - Fax:562-431-2975
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39865207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A47994Medicare UPIN