Provider Demographics
NPI:1376842005
Name:DONG, SHU (NP)
Entity Type:Individual
Prefix:
First Name:SHU
Middle Name:
Last Name:DONG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12359 MALKI RD
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6974
Mailing Address - Country:US
Mailing Address - Phone:951-922-2058
Mailing Address - Fax:888-551-2116
Practice Address - Street 1:12359 MALKI RD
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6974
Practice Address - Country:US
Practice Address - Phone:951-922-2058
Practice Address - Fax:888-551-2116
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner