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General NPI Number Information
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NPI Number | 1609163716
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Entity Type | Organization
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Legal Business Name | 21ST AVENUE PRIMARY CARE PA
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Dates
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Enumeration Date | 07/09/2011
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Last Update Date | 07/09/2011
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Provider Practice Location Address
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Address Line | 534 21ST AVE
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City | PATERSON
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State | NJ
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Zip | 07513-1337
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Country | US
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Telephone | 973-925-5400
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Fax | 973-925-5403
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Provider Business Mailing Address
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Address Line | 534 21ST AVE PATERSON
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City | PATERSON
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State | NJ
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Zip | 07513-1337
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Country | US
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Telephone | 973-925-5400
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Fax | 973-925-5403
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Authorized Official
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Title or Position | OWNER/MEDICAL DIRECTOR
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Name | HECTOR JACOB LEON-WONG
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Credential | MD
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Telephone | 973-925-5400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 25MA05907400
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License Number State | NJ
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