Healthcare Provider Details

I. General information

NPI: 1366375768
Provider Name (Legal Business Name): KENNY WANG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NEW YORK AVE # 25A
SMITHTOWN NY
11787-3448
US

IV. Provider business mailing address

7751 BELFORT PKWY STE 120
JACKSONVILLE FL
32256-6921
US

V. Phone/Fax

Practice location:
  • Phone: 904-372-3943
  • Fax: 904-212-1618
Mailing address:
  • Phone: 904-372-3943
  • Fax: 904-212-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: