Provider Demographics
NPI:1447712906
Name:WONG, CARMEN W
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:W
Last Name:WONG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 ROWLAND WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-5055
Mailing Address - Country:US
Mailing Address - Phone:415-898-9818
Mailing Address - Fax:415-892-3475
Practice Address - Street 1:165 ROWLAND WAY STE 206
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5055
Practice Address - Country:US
Practice Address - Phone:415-898-9818
Practice Address - Fax:415-892-3475
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA5865213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program