Provider Demographics
NPI:1831251990
Name:FONG, ELLIE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELLIE
Middle Name:M
Last Name:FONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:13930 SEAL BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:SEAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90740-5301
Mailing Address - Country:US
Mailing Address - Phone:562-430-8888
Mailing Address - Fax:562-799-0077
Practice Address - Street 1:13930 SEAL BEACH BLVD
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-5301
Practice Address - Country:US
Practice Address - Phone:562-430-8888
Practice Address - Fax:562-799-0077
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA18079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW10995Medicare UPIN