MEDICARE: ERIC WONG

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

General Provider Information

NPI Number	:	1316593031
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIC WONG

Provider Business Mailing Address
First Line	:	576 BROADHOLLOW RD
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5002
Country	:	US
Telephone Number	:	631-359-5859
Fax Number	:

Provider Business Practice Location Address
First Line	:	5111 8TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-2802
Country	:	US
Telephone Number	:	718-686-0108
Fax Number	:

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

Provider Enumeration Date	:	08/19/2019
Last Update Date	:	08/19/2019

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