Healthcare Provider Details

I. General information

NPI: 1649859059
Provider Name (Legal Business Name): ALEX WANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2021
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

260 FAIRFIELD DR E
HOLBROOK NY
11741-2897
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-5800
  • Fax:
Mailing address:
  • Phone: 516-410-2875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: