Provider Demographics
NPI:1346424603
Name:KWO, NGA FAN
Entity Type:Individual
Prefix:
First Name:NGA FAN
Middle Name:
Last Name:KWO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 UNION ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-8004
Mailing Address - Country:US
Mailing Address - Phone:718-640-5408
Mailing Address - Fax:
Practice Address - Street 1:7 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-1202
Practice Address - Country:US
Practice Address - Phone:212-791-5857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048614183500000X
FL36272183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist