Basic Information
| Provider Information | |||||||||
| NPI: | 1699863464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGO | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1525 WEBSTER ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945334997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074232510 | ||||||||
| FaxNumber: | 7074254236 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 B GALE WILSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945333552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074293600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A64486 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | A64486 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 00A644860 | 05 | CA | MEDICAID |