Provider Demographics
NPI:1447817309
Name:TONGOL, LIANE CHRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:LIANE CHRISTINE
Middle Name:
Last Name:TONGOL
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 1:5174 ZINFANDEL LN
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-6329
Mailing Address - Country:US
Mailing Address - Phone:707-319-8128
Mailing Address - Fax:
Practice Address - Street 1:625 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-3785
Practice Address - Country:US
Practice Address - Phone:408-871-5260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant