MEDICARE: AMY FONG

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	30188	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1770675639	OTHER	CA	PHYSICAL EDGE, INC.
2	1689606469	OTHER	CA	PHYSICAL EDGE, INC.

General Provider Information

NPI Number	:	1538259981
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY FONG

Provider Business Mailing Address
First Line	:	102 W GIBSON RD
Second Line	:
City	:	WOODLAND
State	:	CA
Zip	:	95695-4560
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1970 LAKE BLVD STE 4
Second Line	:
City	:	DAVIS
State	:	CA
Zip	:	95616-5663
Country	:	US
Telephone Number	:	530-753-9355
Fax Number	:

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

Provider Enumeration Date	:	10/14/2006
Last Update Date	:	01/03/2022

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Directions to “ AMY FONG ” Practice Location

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