Provider Demographics
NPI:1629138847
Name:WONG, PATRICIA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LYNN
Last Name:WONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301
Mailing Address - Country:US
Mailing Address - Phone:650-473-3173
Mailing Address - Fax:650-473-3177
Practice Address - Street 1:153 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301
Practice Address - Country:US
Practice Address - Phone:650-473-3173
Practice Address - Fax:650-473-3177
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG543820207N00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A52710Medicare UPIN
00G543820Medicare ID - Type Unspecified