MEDICARE: MS. WILFREMIE M WONG-TARLEY RN, PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	008680	NY
2	163W00000X	Registered Nurse	740216	NY

General Provider Information

NPI Number	:	1073160107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WILFREMIE M WONG-TARLEY RN, PTA

Provider Business Mailing Address
First Line	:	1107 FATHER CAPODANNO BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-6059
Country	:	US
Telephone Number	:	212-961-7586
Fax Number	:

Provider Business Practice Location Address
First Line	:	1107 FATHER CAPODANNO BLVD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-6059
Country	:	US
Telephone Number	:	212-961-7586
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2019
Last Update Date	:	08/22/2019

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