Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 123644 | NY |
N | 2080P0210X | Pediatric Nephrologist | 123644 | NY |
NPI | 1861576639 |
---|---|
Provider Name | Winston Wong |
First Address | Latham, NY 12110-2442 |
Second Address | Latham, NY 12110 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2006 |
Last Update Date | 07/12/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01160154 | (05) | NY |
B82031 | (02) | NY |