Healthcare Provider Details

I. General information

NPI: 1225045297
Provider Name (Legal Business Name): KEVIN WONG MSPT,OCS, CAMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4128 71ST ST CA
WOODSIDE NY
11377-3966
US

IV. Provider business mailing address

4128 71ST ST SUITE CA
WOODSIDE NY
11377-3966
US

V. Phone/Fax

Practice location:
  • Phone: 718-874-6779
  • Fax: 718-651-6373
Mailing address:
  • Phone: 718-874-6779
  • Fax: 718-651-6373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number019209-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: