Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RH0003X | Hematology & Oncology | 20A10095 | CA |
NPI | 1063537934 |
---|---|
Provider Name | Glenn Wong |
First Address | Santa Cruz, CA 95062-1323 |
Second Address | Santa Cruz, CA 95065-1702 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2007 |
Last Update Date | 04/11/2011 |