Basic Information
| Provider Information | |||||||||
| NPI: | 1770045650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | MEGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108696883 | ||||||||
| FaxNumber: | 5108696888 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946093108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108696883 | ||||||||
| FaxNumber: | 5108696888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2019 | ||||||||
| LastUpdateDate: | 11/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A180409 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208M00000X | A180409 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | A180409 | 01 | CA | STATE MEDICAL LICENSE | OTHER |