Provider Demographics
NPI:1386607638
Name:DUONG, MARY CHUNG-NING (PAC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CHUNG-NING
Last Name:DUONG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CHUNG-NING
Other - Last Name:TAI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:310-272-7640
Mailing Address - Fax:
Practice Address - Street 1:12414 EXPOSITION BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1016
Practice Address - Country:US
Practice Address - Phone:310-272-7640
Practice Address - Fax:310-272-7656
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15424364SX0200X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P59694Medicare UPIN