Provider Demographics
NPI:1154621860
Name:FONG, RYAN J (RPA-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:J
Last Name:FONG
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Gender:M
Credentials:RPA-C
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Mailing Address - Street 1:362 N BEDFORD ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02333-1148
Mailing Address - Country:US
Mailing Address - Phone:617-481-3100
Mailing Address - Fax:617-481-3105
Practice Address - Street 1:54 MILLER ST STE 201
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4725
Practice Address - Country:US
Practice Address - Phone:617-481-3100
Practice Address - Fax:617-481-3105
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2017-10-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY014255363A00000X
MA4883363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant