Basic Information
| Provider Information | |||||||||
| NPI: | 1497377048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | BRANDON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3875 W BEECHWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937110795 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 121 BARBOZA ST | ||||||||
| Address2: | |||||||||
| City: | MENDOTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936401901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596555000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2020 | ||||||||
| LastUpdateDate: | 10/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 58085 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.