Healthcare Provider Details

I. General information

NPI: 1679929525
Provider Name (Legal Business Name): MARC WREN FONG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

1446 JELLICK AVE UNIT E
ROWLAND HEIGHTS CA
91748-1920
US

V. Phone/Fax

Practice location:
  • Phone: 909-573-6127
  • Fax:
Mailing address:
  • Phone: 909-573-6127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number759678
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000533
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: