Basic Information
| Provider Information | |||||||||
| NPI: | 1578893368 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | 13TH FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956800 | ||||||||
| FaxNumber: | 3126952771 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | 13TH FLOOR | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956800 | ||||||||
| FaxNumber: | 3126952771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2009 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 085003597 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.