Healthcare Provider Details

I. General information

NPI: 1720450646
Provider Name (Legal Business Name): DANIEL FONG JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 W BROADWAY FL 7
SALT LAKE CITY UT
84101-2060
US

IV. Provider business mailing address

777 AVENUE H
POWELL WY
82435-2260
US

V. Phone/Fax

Practice location:
  • Phone: 866-849-0692
  • Fax:
Mailing address:
  • Phone: 307-754-2267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004438
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14268608-1206
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA.0004438
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: