Provider Demographics
NPI:1750054060
Name:WONG, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
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 1:4101 MACON POND RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6319
Mailing Address - Country:US
Mailing Address - Phone:919-684-1975
Mailing Address - Fax:
Practice Address - Street 1:4101 MACON POND RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6319
Practice Address - Country:US
Practice Address - Phone:919-684-1975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical