Provider Demographics
NPI:1871837906
Name:WONG, JENNIFER (RPA-C)
Entity Type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 ROCKAWAY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1665
Mailing Address - Country:US
Mailing Address - Phone:516-887-4343
Mailing Address - Fax:
Practice Address - Street 1:1800 ROCKAWAY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1665
Practice Address - Country:US
Practice Address - Phone:516-887-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0162071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY101399488339Medicaid
NY1629219522Medicare PIN