Healthcare Provider Details

I. General information

NPI: 1174145635
Provider Name (Legal Business Name): CHRISTINE FANG WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 10/11/2026
Certification Date: 10/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 JAMES ST
EDISON NJ
08820-3947
US

IV. Provider business mailing address

65 JAMES ST
EDISON NJ
08820-3947
US

V. Phone/Fax

Practice location:
  • Phone: 732-321-7000
  • Fax:
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00823600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: