Provider Demographics
NPI:1699257774
Name:CHONG, MINWOOK (CRNA)
Entity type:Individual
Prefix:
First Name:MINWOOK
Middle Name:
Last Name:CHONG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 BROOKLINE AVE DEPT OF
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5491
Mailing Address - Country:US
Mailing Address - Phone:617-667-3110
Mailing Address - Fax:617-667-5013
Practice Address - Street 1:330 BROOKLINE AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5491
Practice Address - Country:US
Practice Address - Phone:617-667-3110
Practice Address - Fax:617-667-5013
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2305988367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered