Healthcare Provider Details

I. General information

NPI: 1194308189
Provider Name (Legal Business Name): KAH LOON WAN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 05/02/2026
Certification Date: 05/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

358 NEW DORP LN FL 1
STATEN ISLAND NY
10306-3035
US

IV. Provider business mailing address

358 NEW DORP LN FL 1
STATEN ISLAND NY
10306-3035
US

V. Phone/Fax

Practice location:
  • Phone: 718-980-6688
  • Fax:
Mailing address:
  • Phone: 718-980-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number347224
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: