Provider Demographics
NPI:1669878906
Name:WONG, SIMON
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2444 W BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2306
Mailing Address - Country:US
Mailing Address - Phone:626-759-7175
Mailing Address - Fax:
Practice Address - Street 1:2444 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2306
Practice Address - Country:US
Practice Address - Phone:323-201-4130
Practice Address - Fax:323-201-4134
Is Sole Proprietor?:No
Enumeration Date:2014-11-14
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant