Provider Demographics
NPI:1255623542
Name:WONG, KAM CHAK (PA)
Entity type:Individual
Prefix:
First Name:KAM
Middle Name:CHAK
Last Name:WONG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-1202
Mailing Address - Country:US
Mailing Address - Phone:909-634-3175
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:260 E HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5426
Practice Address - Country:US
Practice Address - Phone:909-629-8088
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant