Provider Demographics
NPI:1053888339
Name:MONG, MIA (PA-C)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:MONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 MYRTLE ST STE 190
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4604
Mailing Address - Country:US
Mailing Address - Phone:814-453-7767
Mailing Address - Fax:
Practice Address - Street 1:2315 MYRTLE ST STE 190
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4604
Practice Address - Country:US
Practice Address - Phone:814-453-7767
Practice Address - Fax:412-359-6620
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2023-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMA060417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant