Provider Demographics
NPI:1992704167
Name:ONG, ROGER JONATHAN (PA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:JONATHAN
Last Name:ONG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16001 W 9 MILE RD # 3
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-2600
Mailing Address - Fax:248-849-2610
Practice Address - Street 1:16001 W 9 MILE RD # 3
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-2600
Practice Address - Fax:248-849-2610
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003732363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1051924OtherNATIONAL-NCCPA
1051924OtherNATIONAL-NCCPA
MIP50231Medicare UPIN