Healthcare Provider Details

I. General information

NPI: 1245021831
Provider Name (Legal Business Name): PHUNG LE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1934 N HIGHWAY 89
CHINO VALLEY AZ
86323-5643
US

IV. Provider business mailing address

PO BOX 811
PAULDEN AZ
86334-0811
US

V. Phone/Fax

Practice location:
  • Phone: 928-667-1968
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11386
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: