Healthcare Provider Details

I. General information

NPI: 1578321618
Provider Name (Legal Business Name): JUSTIN WONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PARAGON WAY STE 300
FREEHOLD NJ
07728-7805
US

IV. Provider business mailing address

4 PARAGON WAY STE 300
FREEHOLD NJ
07728-7805
US

V. Phone/Fax

Practice location:
  • Phone: 732-462-9800
  • Fax: 732-780-4000
Mailing address:
  • Phone: 732-462-9800
  • Fax: 732-780-4000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00841200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: