Provider Demographics
NPI:1801021183
Name:GONG, JUNYANG (NP)
Entity type:Individual
Prefix:
First Name:JUNYANG
Middle Name:
Last Name:GONG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4081 DARBY RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45431-1116
Mailing Address - Country:US
Mailing Address - Phone:646-706-2876
Mailing Address - Fax:
Practice Address - Street 1:2345 PHILADELPHIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1816
Practice Address - Country:US
Practice Address - Phone:937-276-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH019520363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program