Provider Demographics
NPI:1487297644
Name:CHANG, FONG
Entity type:Individual
Prefix:
First Name:FONG
Middle Name:
Last Name:CHANG
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 1:3433 W SHAW AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 E 13TH ST STE D
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6211
Practice Address - Country:US
Practice Address - Phone:209-386-1096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284206164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse