Healthcare Provider Details

I. General information

NPI: 1902339005
Provider Name (Legal Business Name): DARREN THANH LIEM NGO MS, MAT, PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 10/25/2025
Certification Date: 10/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38690 STIVERS ST STE A
FREMONT CA
94536-5276
US

IV. Provider business mailing address

38690 STIVERS ST STE A
FREMONT CA
94536-5276
US

V. Phone/Fax

Practice location:
  • Phone: 510-248-1040
  • Fax: 510-797-7426
Mailing address:
  • Phone: 510-248-1040
  • Fax: 510-797-7426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000031223
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: