Provider Demographics
NPI:1184097768
Name:WONG, CHI WAN (PTA)
Entity type:Individual
Prefix:
First Name:CHI WAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040
Mailing Address - Country:US
Mailing Address - Phone:413-538-4184
Mailing Address - Fax:413-538-4183
Practice Address - Street 1:110 CHERRY STREET
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040
Practice Address - Country:US
Practice Address - Phone:413-538-4184
Practice Address - Fax:413-538-4183
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2018-12-21
Deactivation Date:2018-10-03
Deactivation Code:
Reactivation Date:2018-12-21
Provider Licenses
StateLicense IDTaxonomies
MA8698225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant