Provider Demographics
NPI:1972279560
Name:WONG, ERICA YA-AI
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:YA-AI
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 1:810 LAKE CAROLYN PKWY APT 419
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-4185
Mailing Address - Country:US
Mailing Address - Phone:832-713-0103
Mailing Address - Fax:
Practice Address - Street 1:4202 ROSS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-5116
Practice Address - Country:US
Practice Address - Phone:214-584-2484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68687183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist