Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 33995 | CA |
NPI | 1447428412 |
---|---|
Provider Name | Stacy Lynn Wong |
First Address | Walnut Creek, CA 94598-8396 |
Second Address | Walnut Creek, CA 94598-2444 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/02/2008 |
Last Update Date | 03/03/2014 |