Provider Demographics
NPI:1811319486
Name:FONG, GEORGE
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 RIVER POINTE DR
Mailing Address - Street 2:200
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 RIVER POINTE DR
Practice Address - Street 2:200
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2814
Practice Address - Country:US
Practice Address - Phone:936-494-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03874363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant