MEDICARE: ANDREW JAY FONG

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1912796020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW JAY FONG

Provider Business Mailing Address
First Line	:	31477 MANGO FADE WAY
Second Line	:
City	:	SAN ANTONIO
State	:	FL
Zip	:	33576-4692
Country	:	US
Telephone Number	:	404-781-4652
Fax Number	:

Provider Business Practice Location Address
First Line	:	6421 N FLORIDA AVE, SUITE D-1458, TAMPA, FL 33604-6007
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33604-6007
Country	:	US
Telephone Number	:	404-781-4652
Fax Number	:

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

Provider Enumeration Date	:	05/05/2025
Last Update Date	:	05/03/2026

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Directions to “ ANDREW JAY FONG ” Practice Location

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