Healthcare Provider Details

I. General information

NPI: 1568021186
Provider Name (Legal Business Name): ALEXANDER D WONG DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MEDICAL CENTER BLVD
MARRERO LA
70072-3147
US

IV. Provider business mailing address

1634 CORA DR
BATON ROUGE LA
70815-4319
US

V. Phone/Fax

Practice location:
  • Phone: 504-347-5511
  • Fax:
Mailing address:
  • Phone: 225-773-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number206650
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: