Provider Demographics
NPI:1932201977
Name:WONG, MICHELLE LAI (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LAI
Last Name:WONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20642 JOHN DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5103
Mailing Address - Country:US
Mailing Address - Phone:510-785-5000
Mailing Address - Fax:
Practice Address - Street 1:20642 JOHN DR
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5103
Practice Address - Country:US
Practice Address - Phone:510-785-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15658363A00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant