Basic Information
| Provider Information | |||||||||
| NPI: | 1295917342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1241E DYER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927055611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149784532 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N. PEPPER AVE | ||||||||
| Address2: | SURGERY DEPT 6TH FLOOR | ||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095806210 | ||||||||
| FaxNumber: | 9095801363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2007 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA19420 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA19420 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA19420 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | GR0079700 | 05 | CA | MEDICAID |