Basic Information
| Provider Information | |||||||||
| NPI: | 1386244184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUH | ||||||||
| FirstName: | BONG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 N CEDAR CREST BLVD STE 411 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181042323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843301377 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2545 SCHOENERSVILLE RD FL 2 | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180177300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848845666 | ||||||||
| FaxNumber: | 4848842224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2020 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363AS0400X | MA063456 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | MA063456 | 01 | PA | STATE LICENSE | OTHER |