Healthcare Provider Details

I. General information

NPI: 1952884124
Provider Name (Legal Business Name): LY KONG PHENG JALAO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 DEL PASO BLVD
SACRAMENTO CA
95815-3102
US

IV. Provider business mailing address

6817 E LANE AVE
FRESNO CA
93727-5814
US

V. Phone/Fax

Practice location:
  • Phone: 916-642-1890
  • Fax:
Mailing address:
  • Phone: 209-613-9089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNP95009751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: