MEDICARE: MS. PATRICIA KATHERINE FONG DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	39308	CA

General Provider Information

NPI Number	:	1104253590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PATRICIA KATHERINE FONG DPT

Provider Business Mailing Address
First Line	:	1441 CREEKSIDE DR
Second Line	:	3063
City	:	WALNUT CREEK
State	:	CA
Zip	:	94596-5669
Country	:	US
Telephone Number	:	916-204-9184
Fax Number	:

Provider Business Practice Location Address
First Line	:	1441 CREEKSIDE DR
Second Line	:	3063
City	:	WALNUT CREEK
State	:	CA
Zip	:	94596-5669
Country	:	US
Telephone Number	:	916-204-9184
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2013
Last Update Date	:	10/01/2013

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