Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | 9777 | AZ |
NPI | 1033478573 |
---|---|
Provider Name | Janelle Wong |
First Address | Phoenix, AZ 85014 |
Second Address | Phoenix, AZ 85014 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/05/2012 |
Last Update Date | 03/05/2012 |