Provider Demographics
NPI:1376692277
Name:KWONG, JEFFREY (NP)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:KWONG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 W 14TH ST
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-5002
Mailing Address - Country:US
Mailing Address - Phone:212-620-0144
Mailing Address - Fax:212-691-8588
Practice Address - Street 1:314 W 14TH ST
Practice Address - Street 2:5TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-5002
Practice Address - Country:US
Practice Address - Phone:212-620-0144
Practice Address - Fax:212-691-8588
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO179718363L00000X
NYF305366-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61429716Medicaid
CO61429716Medicaid