Provider Demographics
NPI:1467084103
Name:WONG, SAMUEL (PT,DPT)
Entity Type:Individual
Prefix:
First Name:SAMUEL
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 1:1983 MARCUS AVE STE 119
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1016
Mailing Address - Country:US
Mailing Address - Phone:516-321-7526
Mailing Address - Fax:
Practice Address - Street 1:1554 NORTHERN BLVD FL 3
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3054
Practice Address - Country:US
Practice Address - Phone:516-719-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045434225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist