Provider Demographics
NPI:1710766621
Name:HONG, TIMOTHY S (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:S
Last Name:HONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 W ALPS DR
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-2512
Mailing Address - Country:US
Mailing Address - Phone:909-239-5859
Mailing Address - Fax:
Practice Address - Street 1:2301 E FOOTHILL BLVD STE 100
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4001
Practice Address - Country:US
Practice Address - Phone:626-852-3376
Practice Address - Fax:626-852-3375
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant