MEDICARE: THANH-TAM TIFFANY HUYNH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	56040	CA

General Provider Information

NPI Number	:	1164998803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THANH-TAM TIFFANY HUYNH

Provider Business Mailing Address
First Line	:	770 MAGNOLIA AVE STE 2A
Second Line	:
City	:	CORONA
State	:	CA
Zip	:	92879-3122
Country	:	US
Telephone Number	:	626-548-9444
Fax Number	:

Provider Business Practice Location Address
First Line	:	355 PLACENTIA AVE STE 203
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-3302
Country	:	US
Telephone Number	:	949-650-0616
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2018
Last Update Date	:	04/24/2023

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