Provider Demographics
NPI:1952884124
Name:JALAO, LY KONG PHENG
Entity Type:Individual
Prefix:
First Name:LY KONG PHENG
Middle Name:
Last Name:JALAO
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 1:6817 E LANE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-5814
Mailing Address - Country:US
Mailing Address - Phone:209-613-9089
Mailing Address - Fax:
Practice Address - Street 1:2200 DEL PASO BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-3102
Practice Address - Country:US
Practice Address - Phone:916-642-1890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95009751363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care