Provider Demographics
NPI:1982903878
Name:SONG, QIJUN (LSA, SA-C)
Entity Type:Individual
Prefix:MS
First Name:QIJUN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:LSA, SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 79576
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77279-9576
Mailing Address - Country:US
Mailing Address - Phone:513-312-2223
Mailing Address - Fax:832-201-7900
Practice Address - Street 1:475 BENDWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-8813
Practice Address - Country:US
Practice Address - Phone:281-409-3854
Practice Address - Fax:832-201-7900
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11-114246ZC0007X, 363AS0400X
TXSA00504246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant