MEDICARE: MR. FAN DONG PA-C

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	363AM0700X	Medical Physician Assistant	0010-02621	NC
2	363AS0400X	Surgical Physician Assistant	0010-02621	NC
3	363A00000X	Physician Assistant	0010-02621	NC

General Provider Information

NPI Number	:	1518261155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FAN DONG PA-C

Provider Business Mailing Address
First Line	:	100 KIMEL FOREST DR
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-6074
Country	:	US
Telephone Number	:	336-716-2255
Fax Number	:

Provider Business Practice Location Address
First Line	:	5826 SAMET DR STE 101
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-3661
Country	:	US
Telephone Number	:	336-878-6540
Fax Number	:	336-716-3202

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

Provider Enumeration Date	:	12/22/2010
Last Update Date	:	08/07/2019

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