Provider Demographics
NPI:1639197817
Name:WONG-PAN, RAYMOND (PT)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:WONG-PAN
Suffix:
Gender:M
Credentials:PT
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 188
Mailing Address - Street 2:
Mailing Address - City:GARDINER
Mailing Address - State:NY
Mailing Address - Zip Code:12525-0188
Mailing Address - Country:US
Mailing Address - Phone:845-641-3031
Mailing Address - Fax:
Practice Address - Street 1:2 W CENTER ST
Practice Address - Street 2:SUITE 40
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-2001
Practice Address - Country:US
Practice Address - Phone:845-641-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0171881225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
QL7111Medicare PIN