Provider Demographics
NPI:1720472020
Name:CHUNG, BO RAM (CRNA)
Entity Type:Individual
Prefix:
First Name:BO RAM
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23638 LYONS AVE STE 153
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2513
Mailing Address - Country:US
Mailing Address - Phone:404-642-0900
Mailing Address - Fax:
Practice Address - Street 1:1600 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2814
Practice Address - Country:US
Practice Address - Phone:661-949-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-24
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN194250367500000X
CA95000417367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered