Provider Demographics
NPI:1396381166
Name:GONG, FAN
Entity Type:Individual
Prefix:
First Name:FAN
Middle Name:
Last Name:GONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MOCCASIN TRL
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-4721
Mailing Address - Country:US
Mailing Address - Phone:412-608-0245
Mailing Address - Fax:
Practice Address - Street 1:1200 OLD YORK RD
Practice Address - Street 2:CHIEF OF STAFF OFFICE
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001
Practice Address - Country:US
Practice Address - Phone:215-481-2334
Practice Address - Fax:215-481-4074
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021209207R00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine