Healthcare Provider Details

I. General information

NPI: 1285061168
Provider Name (Legal Business Name): NAM DAO FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2013
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 S. GRAND AVE
GLENDORA CA
91740
US

IV. Provider business mailing address

16411 MCFADDEN AVE APT 323
TUSTIN CA
92780
US

V. Phone/Fax

Practice location:
  • Phone: 626-857-2500
  • Fax:
Mailing address:
  • Phone: 714-251-1626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number23751
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: