Basic Information
| Provider Information | |||||||||
| NPI: | 1336525609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AUSILIO | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1990 N CALIFORNIA BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945967249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252255837 | ||||||||
| FaxNumber: | 9252255838 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MISSION BLVD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956422564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092237555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 08/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 52720 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.