Provider Demographics
NPI:1841969995
Name:WONG, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25121 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1354
Mailing Address - Country:US
Mailing Address - Phone:718-780-0050
Mailing Address - Fax:
Practice Address - Street 1:25121 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1354
Practice Address - Country:US
Practice Address - Phone:718-780-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-12
Last Update Date:2021-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1100X
NY009419156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic