Healthcare Provider Details

I. General information

NPI: 1104396076
Provider Name (Legal Business Name): RAYMOND KWONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 ROXBURY RD
ROCKFORD IL
61107-5059
US

IV. Provider business mailing address

444 ROXBURY RD
ROCKFORD IL
61107-5059
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-3000
  • Fax: 815-391-5076
Mailing address:
  • Phone: 815-398-3000
  • Fax: 815-391-5076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-006788
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4564
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: