Provider Demographics
NPI:1497307763
Name:WONG, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
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 1:1155 MILL ST # MSM14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-3000
Practice Address - Street 1:901 E 2ND ST STE 300
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1175
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-3901
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59545363A00000X
NVPA2388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA59545OtherCALIFORNIA PA LICENSE
NVPA2388OtherNEVADA PA LICENSE