Provider Demographics
NPI:1295781979
Name:WONG, PATRICIA W (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:W
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 1:528 PALISADES DR UNIT 149
Mailing Address - Street 2:
Mailing Address - City:PACIFIC PALISADES
Mailing Address - State:CA
Mailing Address - Zip Code:90272-2844
Mailing Address - Country:US
Mailing Address - Phone:310-779-4534
Mailing Address - Fax:
Practice Address - Street 1:1338 S HOPE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-2902
Practice Address - Country:US
Practice Address - Phone:213-742-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67231207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A672310Medicaid
CAWA67231CMedicare PIN
H13064Medicare UPIN