Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | PT13998 | CA |
N | 2251S0007X | Physical Therapist - Sports | PT13998 | CA |
N | 2251X0800X | Physical Therapist - Orthopedic | PT13998 | CA |
NPI | 1255534418 |
---|---|
Provider Name | Brian William Wong |
First Address | Tustin, CA 92780-6953 |
Second Address | Tustin, CA 92780-6953 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PT13998 | PT LICENSE# (01) | CA |