Healthcare Provider Details

I. General information

NPI: 1265051155
Provider Name (Legal Business Name): ALBERT WONG PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 05/03/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CELEBRATION PL # C200
KISSIMMEE FL
34747-4970
US

IV. Provider business mailing address

1919 FL-50
CLERMONT FL
34711-6089
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-4003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA26971
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: