Provider Demographics
NPI:1104355098
Name:WONG, KATHERINE ELIZABETH (CPNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:WONG
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 GERMANTOWN AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122
Mailing Address - Country:US
Mailing Address - Phone:917-620-9396
Mailing Address - Fax:
Practice Address - Street 1:2085 N 63RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151-2675
Practice Address - Country:US
Practice Address - Phone:215-452-0304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00730000363L00000X
PASP017222363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033698760001Medicaid