Healthcare Provider Details

I. General information

NPI: 1538056114
Provider Name (Legal Business Name): JOHAN HSU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2025
Last Update Date: 06/18/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NELLIS AFB 4700 LAS VEGAS BLVD
APO AA
89191
US

IV. Provider business mailing address

1609 BLUE HAVEN DR
ROWLAND HEIGHTS CA
91748-2411
US

V. Phone/Fax

Practice location:
  • Phone: 909-859-5759
  • Fax:
Mailing address:
  • Phone: 909-859-5759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: