Healthcare Provider Details

I. General information

NPI: 1750130068
Provider Name (Legal Business Name): ANDREW DAT VU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1819
US

IV. Provider business mailing address

400 N PEPPER AVE # 205
COLTON CA
92324-1801
US

V. Phone/Fax

Practice location:
  • Phone: 877-873-2762
  • Fax:
Mailing address:
  • Phone: 714-804-3746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: