Provider Demographics
NPI:1609401207
Name:TO, WONJIN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:WONJIN
Middle Name:
Last Name:TO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 709
Mailing Address - Street 2:
Mailing Address - City:GLADWYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19035-0709
Mailing Address - Country:US
Mailing Address - Phone:484-494-8646
Mailing Address - Fax:484-494-0226
Practice Address - Street 1:2821 ISLAND AVE STE D&E
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19153-2300
Practice Address - Country:US
Practice Address - Phone:215-863-6110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1316902885225400000X
PASP020119363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner