Healthcare Provider Details

I. General information

NPI: 1083982995
Provider Name (Legal Business Name): DONALD PLONG MS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11215 LONG BEACH BLVD
LYNWOOD CA
90262-4292
US

IV. Provider business mailing address

11215 LONG BEACH BLVD STE 1006
LYNWOOD CA
90262-4292
US

V. Phone/Fax

Practice location:
  • Phone: 310-638-4100
  • Fax:
Mailing address:
  • Phone: 310-638-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: