Provider Demographics
NPI:1790439859
Name:VONG, WENDY MUI (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:MUI
Last Name:VONG
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 1:366 KILLIAN HILL RD SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-4065
Mailing Address - Country:US
Mailing Address - Phone:678-814-5482
Mailing Address - Fax:
Practice Address - Street 1:4072 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-2297
Practice Address - Country:US
Practice Address - Phone:678-905-0236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant