Healthcare Provider Details

I. General information

NPI: 1033274238
Provider Name (Legal Business Name): ANTOINETTE T KHOWONG MEDICAL DOCTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 12/16/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MEDICAL PLAZA DR SUITE 250
ROSEVILLE CA
95661-2865
US

IV. Provider business mailing address

5 MEDICAL PLAZA DR SUITE 250
ROSEVILLE CA
95661-2865
US

V. Phone/Fax

Practice location:
  • Phone: 916-782-2229
  • Fax: 916-797-9414
Mailing address:
  • Phone: 916-782-2229
  • Fax: 916-797-9414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6252
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA105245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: