Provider Demographics
NPI:1538269337
Name:SONG, SOO JA (CRNA)
Entity type:Individual
Prefix:MS
First Name:SOO
Middle Name:JA
Last Name:SONG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 22678
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90801-2678
Mailing Address - Country:US
Mailing Address - Phone:714-935-0073
Mailing Address - Fax:714-935-0075
Practice Address - Street 1:2776 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2613
Practice Address - Country:US
Practice Address - Phone:714-935-0073
Practice Address - Fax:714-935-0075
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACRNA672372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider