Healthcare Provider Details

I. General information

NPI: 1992933055
Provider Name (Legal Business Name): TIM VAN LUONG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7761 GARDEN GROVE BLVD
GARDEN GROVE CA
92841-4200
US

IV. Provider business mailing address

6958 NEW RIDGE DR
RIVERSIDE CA
92506-4912
US

V. Phone/Fax

Practice location:
  • Phone: 714-898-8888
  • Fax: 714-901-7580
Mailing address:
  • Phone: 951-780-9787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: