Basic Information
| Provider Information | |||||||||
| NPI: | 1063988798 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LAI | ||||||||
| FirstName: | KIT | ||||||||
| MiddleName: | WON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 PROSPECT AVE APT 205 | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806287624 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519962000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2018 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 25MP00556400 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.