Healthcare Provider Details

I. General information

NPI: 1841751815
Provider Name (Legal Business Name): MA KOREENA JAYNE YU TRAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2019
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 VALLEY VISTA DR
DIAMOND BAR CA
91765-3929
US

IV. Provider business mailing address

1514 VALLEY VISTA DR
DIAMOND BAR CA
91765-3929
US

V. Phone/Fax

Practice location:
  • Phone: 909-860-1144
  • Fax:
Mailing address:
  • Phone: 909-860-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: