Healthcare Provider Details

I. General information

NPI: 1174257414
Provider Name (Legal Business Name): DONGWHAN DUSTIN IM PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 SUNNY CREST DR STE 2600
FULLERTON CA
92835-3644
US

IV. Provider business mailing address

PO BOX 5532
IRVINE CA
92616-5532
US

V. Phone/Fax

Practice location:
  • Phone: 714-446-5590
  • Fax: 714-446-5592
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: