Healthcare Provider Details

I. General information

NPI: 1861576639
Provider Name (Legal Business Name): WINSTON WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CRHP-711 TROY-SCHENECTADY RD SUITE 101
LATHAM NY
12110
US

IV. Provider business mailing address

711 TROY SCHENECTADY RD SUITE 201
LATHAM NY
12110-2442
US

V. Phone/Fax

Practice location:
  • Phone: 518-783-3110
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number123644
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number123644
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: