Provider Demographics
NPI:1750915757
Name:WONG, KEVIN GUANWEI
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:GUANWEI
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 1:2148 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6345
Mailing Address - Country:US
Mailing Address - Phone:949-264-6560
Mailing Address - Fax:
Practice Address - Street 1:1150 HARTER PKWY
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993-2642
Practice Address - Country:US
Practice Address - Phone:530-751-2701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist