Provider Demographics
NPI:1689197139
Name:WON, CHONGMYONG DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:CHONGMYONG
Middle Name:DANIEL
Last Name:WON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1301 SIGMAN RD NE STE 100
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3819
Mailing Address - Country:US
Mailing Address - Phone:770-760-9360
Mailing Address - Fax:770-760-9303
Practice Address - Street 1:1765 OLD WEST BROAD ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2853
Practice Address - Country:US
Practice Address - Phone:706-549-1663
Practice Address - Fax:706-546-8792
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2023-03-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA8489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
14192129OtherCAQH NUMBER