Provider Demographics
NPI:1821439811
Name:HO, IRENE GUNG (PA-C, MBA)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:GUNG
Last Name:HO
Suffix:
Gender:F
Credentials:PA-C, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 VINEVILLE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2323
Mailing Address - Country:US
Mailing Address - Phone:478-471-0273
Mailing Address - Fax:
Practice Address - Street 1:3203 VINEVILLE AVE STE A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204
Practice Address - Country:US
Practice Address - Phone:478-471-0273
Practice Address - Fax:478-471-1471
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2496363A00000X
GA006861363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003177670BMedicaid
GA003177670CMedicaid
GA003177670AMedicaid