Basic Information
| Provider Information | |||||||||
| NPI: | 1407888910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONG | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | CHI-MING | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4310 COLBY AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982032338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252528102 | ||||||||
| FaxNumber: | 4253390835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 05/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 44010 | WA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 8406977 | 05 | WA | MEDICAID | I13494G | 01 | WA | MEDICARE ID-PIN | OTHER |