Provider Demographics
NPI:1376020321
Name:WONG, MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8007 14TH AVE BSMT
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11228-3101
Mailing Address - Country:US
Mailing Address - Phone:646-651-0443
Mailing Address - Fax:
Practice Address - Street 1:240 E 38TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2708
Practice Address - Country:US
Practice Address - Phone:646-501-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-23
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022493363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY022493OtherNYS PHYSICIAN ASSISTANT LICENSE