Basic Information
| Provider Information | |||||||||
| NPI: | 1336659218 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | MAIL DROP 4S-205 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586057171 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15004 INNOVATION DRIVE (S97) | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585547439 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2017 | ||||||||
| LastUpdateDate: | 12/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/26/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.