Healthcare Provider Details

I. General information

NPI: 1205587607
Provider Name (Legal Business Name): NICHOLAS WILLIAM FONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 LONE TREE WAY
ANTIOCH CA
94509-6200
US

IV. Provider business mailing address

3901 LONE TREE WAY
ANTIOCH CA
94509-6200
US

V. Phone/Fax

Practice location:
  • Phone: 925-779-7273
  • Fax:
Mailing address:
  • Phone: 925-779-7273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60749
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: