Healthcare Provider Details

I. General information

NPI: 1972081016
Provider Name (Legal Business Name): GEORGE KIN WAH WAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2018
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 1ST AVE
NEW YORK NY
10016-9196
US

IV. Provider business mailing address

462 1ST AVE NBV 15 SOUTH 5
NEW YORK NY
10016-9196
US

V. Phone/Fax

Practice location:
  • Phone: 212-562-3917
  • Fax:
Mailing address:
  • Phone: 212-562-3917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0022417
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: