Healthcare Provider Details

I. General information

NPI: 1720472020
Provider Name (Legal Business Name): BO RAM CHUNG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 12/23/2022
Certification Date: 12/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W AVENUE J
LANCASTER CA
93534-2814
US

IV. Provider business mailing address

23638 LYONS AVE STE 153
NEWHALL CA
91321-2513
US

V. Phone/Fax

Practice location:
  • Phone: 661-949-5000
  • Fax:
Mailing address:
  • Phone: 404-642-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN194250
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000417
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: