1043290703 NPI number — MS. SO-FONG WONG FNP, CNS, CDE

Table of content: RACIEL LEE NP (NPI 1386078970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043290703 NPI number — MS. SO-FONG WONG FNP, CNS, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WONG
Provider First Name:
SO-FONG
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP, CNS, CDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043290703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5050 CRENSHAW RD
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77505-3138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-487-1000
Provider Business Mailing Address Fax Number:
832-399-4110

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5050 CRENSHAW RD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77505-3138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-487-1000
Provider Business Practice Location Address Fax Number:
832-399-4110
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WD0400X , with the licence number:  21210407 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SA2200X , with the licence number: AP110586 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP110586 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 654824 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SA2200X , with the licence number: 654824 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CN8558 . This is a "PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 093873001 . This is a "TPI" identifier . This identifiers is of the category "OTHER".




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