Provider Demographics
NPI:1689399289
Name:FONG, TAYLOR RAEANNE (PA)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RAEANNE
Last Name:FONG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10170 W TROPICANA AVE # 156-252
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8465
Mailing Address - Country:US
Mailing Address - Phone:702-732-1493
Mailing Address - Fax:702-732-1080
Practice Address - Street 1:1 BREAKTHROUGH WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-3011
Practice Address - Country:US
Practice Address - Phone:702-732-1493
Practice Address - Fax:702-732-1080
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVPA2787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant