Provider Demographics
NPI:1679219109
Name:FONG, SAMANTHA JUSTINE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:JUSTINE
Last Name:FONG
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 1:1047 MONTEREY AVE
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-3717
Mailing Address - Country:US
Mailing Address - Phone:650-787-2018
Mailing Address - Fax:
Practice Address - Street 1:1047 MONTEREY AVE
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-3717
Practice Address - Country:US
Practice Address - Phone:650-787-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-08
Last Update Date:2022-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist