Healthcare Provider Details

I. General information

NPI: 1881465656
Provider Name (Legal Business Name): SE JONG HONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 02/08/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL (BDAACH) UNIT #15245; BLDG 3031
APO AP
96271-5245
US

IV. Provider business mailing address

BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL (BDAACH) UNIT #15245; BLDG 3031
APO AP
96271
US

V. Phone/Fax

Practice location:
  • Phone: 315-737-2764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1213772
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: