Healthcare Provider Details

I. General information

NPI: 1699726513
Provider Name (Legal Business Name): AMELIA JAN WONG CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 MADISON ST GOUVERNEUR HEALTHCARE SERVICES PEDIATRICS
NEW YORK NY
10002-7537
US

IV. Provider business mailing address

30 W 60TH ST APT. 11F
NEW YORK NY
10023-7902
US

V. Phone/Fax

Practice location:
  • Phone: 212-238-7212
  • Fax: 212-238-7799
Mailing address:
  • Phone: 212-489-6801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF380429-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: