Provider Demographics
NPI:1811663594
Name:WONG, CRESTLEY PATRICIA (OD)
Entity type:Individual
Prefix:DR
First Name:CRESTLEY
Middle Name:PATRICIA
Last Name:WONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9652 HOLLY CREEK CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-8309
Mailing Address - Country:US
Mailing Address - Phone:916-833-4748
Mailing Address - Fax:
Practice Address - Street 1:101 N CORONADO DR STE A
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6359
Practice Address - Country:US
Practice Address - Phone:520-459-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34923152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist