Provider Demographics
NPI:1487980736
Name:WONG, ETTA CHI ON (LAC)
Entity type:Individual
Prefix:
First Name:ETTA
Middle Name:CHI ON
Last Name:WONG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46292 WARM SPRINGS BLVD
Mailing Address - Street 2:#678
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539
Mailing Address - Country:US
Mailing Address - Phone:510-657-8788
Mailing Address - Fax:
Practice Address - Street 1:46292 WARM SPRINGS BLVD
Practice Address - Street 2:#678
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94539
Practice Address - Country:US
Practice Address - Phone:510-657-8788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC13136171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist