Provider Demographics
NPI:1679392245
Name:FOK, CONNIE MAN WA
Entity type:Individual
Prefix:
First Name:CONNIE MAN WA
Middle Name:
Last Name:FOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 LILY CT
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2410 SAN RAMON VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1671
Practice Address - Country:US
Practice Address - Phone:925-487-7349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-11-18
Deactivation Date:2024-11-07
Deactivation Code:
Reactivation Date:2024-11-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist