Provider Demographics
NPI:1487365938
Name:WONG, BRADFORD (PT, MPA)
Entity type:Individual
Prefix:MR
First Name:BRADFORD
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PT, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 ALEGRE CT
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4909
Mailing Address - Country:US
Mailing Address - Phone:925-552-0268
Mailing Address - Fax:
Practice Address - Street 1:35 ALEGRE CT
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94526-4909
Practice Address - Country:US
Practice Address - Phone:925-552-0268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT17401261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy