Provider Demographics
NPI:1376664458
Name:FANG, KO BRUCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KO
Middle Name:BRUCE
Last Name:FANG
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9895 SELVA WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757
Mailing Address - Country:US
Mailing Address - Phone:916-296-5089
Mailing Address - Fax:559-229-0227
Practice Address - Street 1:2822 N. BLACKSTONE AVENUE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703
Practice Address - Country:US
Practice Address - Phone:559-229-0227
Practice Address - Fax:559-229-0227
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18841103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical