Provider Demographics
NPI:1801247176
Name:SONG, GUOQING (PA-C)
Entity type:Individual
Prefix:
First Name:GUOQING
Middle Name:
Last Name:SONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:920-831-5050
Mailing Address - Fax:920-738-6507
Practice Address - Street 1:2400 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8728
Practice Address - Country:US
Practice Address - Phone:920-831-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-005846363AS0400X
WI4030363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical