Provider Demographics
NPI:1588903264
Name:WONG, JONATHAN (NP)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 CARNEGIE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3819
Mailing Address - Country:US
Mailing Address - Phone:347-513-1676
Mailing Address - Fax:
Practice Address - Street 1:49 CARNEGIE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3819
Practice Address - Country:US
Practice Address - Phone:347-513-1676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-31
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302155164W00000X
NY310033363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse