Provider Demographics
NPI:1336819689
Name:WONG, KAREN L
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:L
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 1:1414 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-5102
Mailing Address - Country:US
Mailing Address - Phone:650-637-9777
Mailing Address - Fax:
Practice Address - Street 1:1414 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-5102
Practice Address - Country:US
Practice Address - Phone:650-637-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85128183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist