Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | 176719 | NY |
NPI | 1003904905 |
---|---|
Provider Name | Jane Fong |
First Address | Brooklyn, NY 11215-3689 |
Second Address | Brooklyn, NY 11215-3689 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01255861 | (05) | NY |
E94824 | (02) |