Provider Demographics
NPI:1508470709
Name:WONG, BRYAN YING (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:YING
Last Name:WONG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 S MORGAN ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6904
Mailing Address - Country:US
Mailing Address - Phone:214-771-8478
Mailing Address - Fax:
Practice Address - Street 1:3420 S MORGAN ST APT 2E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6904
Practice Address - Country:US
Practice Address - Phone:214-771-8478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant