Healthcare Provider Details

I. General information

NPI: 1477924132
Provider Name (Legal Business Name): JOHN LONG HOANG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E. FOOTHILL STE C
POMONA CA
91767-3031
US

IV. Provider business mailing address

840 TOWNE CENTER DRIVE
POMONA CA
91767-5900
US

V. Phone/Fax

Practice location:
  • Phone: 909-398-4895
  • Fax: 909-398-4925
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-1488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number52922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: