Provider Demographics
NPI:1508250705
Name:WONG, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PARSONAGE RD STE 410
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-2429
Mailing Address - Country:US
Mailing Address - Phone:732-795-6130
Mailing Address - Fax:732-463-5535
Practice Address - Street 1:10 PARSONAGE RD STE 410
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837
Practice Address - Country:US
Practice Address - Phone:732-795-6130
Practice Address - Fax:732-463-5535
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10413000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
223378948OtherFMMS EIN#