Basic Information
| Provider Information | |||||||||
| NPI: | 1336705763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | AVA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14910 BURROWS WAY | ||||||||
| Address2: | |||||||||
| City: | EASTVALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928804503 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 115 MALL DR | ||||||||
| Address2: | |||||||||
| City: | HANFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932305786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5595829000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2019 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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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 | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.