Provider Demographics
NPI:1174589931
Name:WONG, ELISA NEREZ (BS, PA-C)
Entity type:Individual
Prefix:MS
First Name:ELISA
Middle Name:NEREZ
Last Name:WONG
Suffix:
Gender:F
Credentials:BS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 MISSION AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2933
Mailing Address - Country:US
Mailing Address - Phone:916-972-0882
Mailing Address - Fax:916-972-0649
Practice Address - Street 1:3650 MISSION AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2933
Practice Address - Country:US
Practice Address - Phone:916-972-0882
Practice Address - Fax:916-972-0649
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 15291363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G349230OtherBLUE SHIELD
CA00G349230OtherBLUE SHIELD
CAA46148Medicare UPIN