Healthcare Provider Details

I. General information

NPI: 1669969010
Provider Name (Legal Business Name): TRISTON ANTHONY WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 CHESTNUT ST STE 210
PHILADELPHIA PA
19107-4405
US

IV. Provider business mailing address

109 W 27TH ST RM 5S
NEW YORK NY
10001-6208
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-8420
  • Fax:
Mailing address:
  • Phone: 833-351-8255
  • Fax: 888-815-3583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD476019
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: