MEDICARE: AUSTIN VANNATH PLONG PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	15560	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366622433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUSTIN VANNATH PLONG PA-C

Provider Business Mailing Address
First Line	:	2661 E FLORENCE AVE
Second Line	:	SUITE D-1
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4793
Country	:	US
Telephone Number	:	323-588-6113
Fax Number	:	323-588-6468

Provider Business Practice Location Address
First Line	:	2661 E FLORENCE AVE
Second Line	:	SUITE D-1
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4793
Country	:	US
Telephone Number	:	323-588-6113
Fax Number	:	323-588-6468

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2007
Last Update Date	:	11/06/2007

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