Basic Information
| Provider Information | |||||||||
| NPI: | 1437423647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088520600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 123 SUMMER ST | ||||||||
| Address2: | SUITE 150S | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083683110 | ||||||||
| FaxNumber: | 5083683113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2012 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 082522-23 | NH | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | RN2258359 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 3103202 | 05 | NH | MEDICAID |