Provider Demographics
NPI:1033282397
Name:FUNG-A-WING, N. ROEL (PT)
Entity Type:Individual
Prefix:MR
First Name:N.
Middle Name:ROEL
Last Name:FUNG-A-WING
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 ROSWELL RD
Mailing Address - Street 2:STE 100A
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8811
Mailing Address - Country:US
Mailing Address - Phone:770-578-4343
Mailing Address - Fax:770-578-4342
Practice Address - Street 1:3901 ROSWELL RD
Practice Address - Street 2:STE 100A
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8811
Practice Address - Country:US
Practice Address - Phone:770-578-4343
Practice Address - Fax:770-578-4342
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003341225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4034861OtherBCBS
GA65BBBGGMedicare PIN
S95513Medicare UPIN
65BBBGGMedicare ID - Type Unspecified
GAS95513Medicare UPIN