Provider Demographics
NPI:1205804036
Name:LI, XIN-NONG (MD)
Entity type:Individual
Prefix:
First Name:XIN-NONG
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 MERCY CT
Mailing Address - Street 2:STE 130
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-3158
Mailing Address - Country:US
Mailing Address - Phone:916-961-3084
Mailing Address - Fax:916-961-3018
Practice Address - Street 1:6600 MERCY CT
Practice Address - Street 2:STE 130
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-3158
Practice Address - Country:US
Practice Address - Phone:916-961-3084
Practice Address - Fax:916-961-3018
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA067508207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A675080Medicaid
CA00A675080Medicaid
H04886Medicare UPIN