Provider Demographics
NPI:1063882785
Name:WONG, JESSICA DANIELLE (RPA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:DANIELLE
Last Name:WONG
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W 35TH STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001
Mailing Address - Country:US
Mailing Address - Phone:212-736-5900
Mailing Address - Fax:212-290-2724
Practice Address - Street 1:311 W 35TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-1701
Practice Address - Country:US
Practice Address - Phone:212-736-5900
Practice Address - Fax:212-290-2724
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019153363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical