Provider Demographics
NPI:1396984118
Name:WONG, JORDAN (PA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 N MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-3906
Mailing Address - Country:US
Mailing Address - Phone:619-579-8373
Mailing Address - Fax:
Practice Address - Street 1:234 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3906
Practice Address - Country:US
Practice Address - Phone:619-579-8373
Practice Address - Fax:619-579-8155
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20219363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant