Provider Demographics
NPI:1629014873
Name:CHONG, RENEE MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MICHELLE
Last Name:CHONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660519
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0519
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:525 N GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1202
Practice Address - Country:US
Practice Address - Phone:626-307-2129
Practice Address - Fax:626-307-2056
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18233363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18233Medicaid
CAPA18233Medicaid
CAWPA18233BMedicare PIN
CAWPA18233AMedicare PIN