Healthcare Provider Details

I. General information

NPI: 1780139402
Provider Name (Legal Business Name): CHELSEA KATELYN FONG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO, MSC11 6025
ALBUQUERQUE NM
87131-6025
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2016-0046
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: