Healthcare Provider Details

I. General information

NPI: 1467084103
Provider Name (Legal Business Name): SAMUEL WONG PT,DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 NORTHERN BLVD FL 3
MANHASSET NY
11030-3054
US

IV. Provider business mailing address

1983 MARCUS AVE STE 119
NEW HYDE PARK NY
11042-1016
US

V. Phone/Fax

Practice location:
  • Phone: 516-719-3700
  • Fax:
Mailing address:
  • Phone: 516-321-7526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number045434
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: