Healthcare Provider Details

I. General information

NPI: 1306837711
Provider Name (Legal Business Name): IRIS C WONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 04/02/2022
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 W SQUANTUM ST
NORTH QUINCY MA
02171-2122
US

IV. Provider business mailing address

110 W SQUANTUM ST
NORTH QUINCY MA
02171-2122
US

V. Phone/Fax

Practice location:
  • Phone: 617-376-3000
  • Fax: 617-376-3024
Mailing address:
  • Phone: 617-376-3000
  • Fax: 173-763-0246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number233807
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: