Provider Demographics
NPI:1477196079
Name:WONG, ADRIANNE
Entity type:Individual
Prefix:
First Name:ADRIANNE
Middle Name:
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 1:1 HOPE DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-0221
Mailing Address - Country:US
Mailing Address - Phone:714-247-0300
Mailing Address - Fax:
Practice Address - Street 1:5215 TORRANCE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4009
Practice Address - Country:US
Practice Address - Phone:424-212-5361
Practice Address - Fax:310-316-3466
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty