Provider Demographics
NPI:1740017730
Name:WONG, TIANNA NICOLE
Entity type:Individual
Prefix:
First Name:TIANNA
Middle Name:NICOLE
Last Name:WONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 OLD FARM RD
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-2914
Mailing Address - Country:US
Mailing Address - Phone:347-684-3151
Mailing Address - Fax:
Practice Address - Street 1:140 OLD FARM RD
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-2914
Practice Address - Country:US
Practice Address - Phone:347-684-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant