Provider Demographics
NPI:1922469949
Name:FONG, PATTY
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:
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 1:6 BLUE WATER CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-4805
Mailing Address - Country:US
Mailing Address - Phone:916-477-0043
Mailing Address - Fax:
Practice Address - Street 1:2360 STOCKTON BOULEVARD
Practice Address - Street 2:SUITE 1200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-477-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 64192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist