Healthcare Provider Details

I. General information

NPI: 1629473707
Provider Name (Legal Business Name): JORGE A FONG ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 W 20TH AVE STE 105
HIALEAH FL
33012-4532
US

IV. Provider business mailing address

3805 W 20TH AVE STE 105
HIALEAH FL
33012-4532
US

V. Phone/Fax

Practice location:
  • Phone: 305-557-2277
  • Fax: 786-621-7818
Mailing address:
  • Phone: 305-557-2277
  • Fax: 786-621-7818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9297646
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: