Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 14219 | CA |
NPI | 1003194234 |
---|---|
Provider Name | Jamie Wong |
First Address | Newark, CA 94560-2667 |
Second Address | Fremont, CA 94538-1736 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2011 |
Last Update Date | 11/05/2020 |