Basic Information
| Provider Information | |||||||||
| NPI: | 1659023448 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONG | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | REGISTERED NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | NEW HYDE PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110401966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9173630793 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13626 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113546533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188861200 | ||||||||
| FaxNumber: | 2122262289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2022 | ||||||||
| LastUpdateDate: | 01/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 738041 | NY | Y | Nursing Service Providers | Registered Nurse |
No ID Information.