Healthcare Provider Details

I. General information

NPI: 1417540006
Provider Name (Legal Business Name): JUSTIN WONG PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 GRAND ISLAND BLVD
GRAND ISLAND NY
14072-2249
US

IV. Provider business mailing address

1801 GRAND ISLAND BLVD STE 100
GRAND ISLAND NY
14072-2249
US

V. Phone/Fax

Practice location:
  • Phone: 716-773-4323
  • Fax: 716-773-9418
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number046160
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: