Basic Information
| Provider Information | |||||||||
| NPI: | 1922727213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | HENRICK RYAN | ||||||||
| MiddleName: | CHUA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13521 LATROBE LN | ||||||||
| Address2: | |||||||||
| City: | CLARKSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208719420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016481294 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 S CATON AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212295201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6672346000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2022 | ||||||||
| LastUpdateDate: | 08/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.