Provider Demographics
NPI:1205983509
Name:FONG, ANDREA (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 N TOWN CENTER DR
Mailing Address - Street 2:SUITE 512
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0514
Mailing Address - Country:US
Mailing Address - Phone:702-796-7546
Mailing Address - Fax:702-869-6146
Practice Address - Street 1:653 N TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0514
Practice Address - Country:US
Practice Address - Phone:702-796-7546
Practice Address - Fax:702-869-6146
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV727207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV104198Medicare PIN
NVF11072Medicare UPIN