Provider Demographics
NPI:1629759857
Name:KHONG, MARIO (DNP)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:KHONG
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CLEMENTINE ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-1615
Mailing Address - Country:US
Mailing Address - Phone:714-589-4507
Mailing Address - Fax:
Practice Address - Street 1:1900 CLEMENTINE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-1615
Practice Address - Country:US
Practice Address - Phone:714-589-4507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95076500163W00000X
CA95002186367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse