Provider Demographics
NPI:1972003499
Name:WONG, SAN (APRN)
Entity Type:Individual
Prefix:
First Name:SAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:APRN
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-3800
Mailing Address - Fax:232-343-3993
Practice Address - Street 1:2780 CLEVELAND AVE STE 819
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901
Practice Address - Country:US
Practice Address - Phone:239-343-3800
Practice Address - Fax:239-343-3993
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9232935364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024233400Medicaid