Provider Demographics
NPI:1417540006
Name:WONG, JUSTIN (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 GRAND ISLAND BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-2249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 GRAND ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-2249
Practice Address - Country:US
Practice Address - Phone:716-773-4323
Practice Address - Fax:716-773-9418
Is Sole Proprietor?:No
Enumeration Date:2021-02-16
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046160225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist