Healthcare Provider Details

I. General information

NPI: 1831251990
Provider Name (Legal Business Name): ELLIE M FONG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 11/16/2025
Certification Date: 11/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13930 SEAL BEACH BLVD
SEAL BEACH CA
90740-5301
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 562-430-8888
  • Fax: 562-799-0077
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number18079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: