Provider Demographics
NPI:1356063341
Name:AN, SI WOO
Entity type:Individual
Prefix:
First Name:SI WOO
Middle Name:
Last Name:AN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WILD TURKEY LN
Mailing Address - Street 2:
Mailing Address - City:ROCK TAVERN
Mailing Address - State:NY
Mailing Address - Zip Code:12575-5419
Mailing Address - Country:US
Mailing Address - Phone:201-364-8465
Mailing Address - Fax:
Practice Address - Street 1:3 WILD TURKEY LN
Practice Address - Street 2:
Practice Address - City:ROCK TAVERN
Practice Address - State:NY
Practice Address - Zip Code:12575-5419
Practice Address - Country:US
Practice Address - Phone:201-364-8465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant