Provider Demographics
NPI:1538488101
Name:SONG, BO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BO
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:BORA
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2720 N HARBOR BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2720 N HARBOR BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2609
Practice Address - Country:US
Practice Address - Phone:714-449-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19789363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant