Healthcare Provider Details

I. General information

NPI: 1245779016
Provider Name (Legal Business Name): THU PHAN MSN, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9333 IMPERIAL HWY
DOWNEY CA
90242-2812
US

IV. Provider business mailing address

9333 IMPERIAL HWY
DOWNEY CA
90242-2812
US

V. Phone/Fax

Practice location:
  • Phone: 800-823-4040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number803544
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95006018
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: