Provider Demographics
NPI:1851870422
Name:WONG, BRANDON MATTHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:MATTHEW
Last Name:WONG
Suffix:
Gender:M
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 1:1100 S ELISEO DR STE 2A
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2017
Mailing Address - Country:US
Mailing Address - Phone:415-464-5400
Mailing Address - Fax:415-464-5413
Practice Address - Street 1:1100 S ELISEO DR STE 2A
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2017
Practice Address - Country:US
Practice Address - Phone:415-464-5400
Practice Address - Fax:415-464-5413
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant