Provider Demographics
NPI:1518690908
Name:WONG, KRISTYN
Entity Type:Individual
Prefix:MS
First Name:KRISTYN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 MORGAN STANLEY AVE UNIT 118
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1981
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2884 WELLNESS AVE STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8427
Practice Address - Country:US
Practice Address - Phone:386-339-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9115955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant