Healthcare Provider Details

I. General information

NPI: 1215319546
Provider Name (Legal Business Name): LIEN MY PHAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 W 117TH ST STE 300
HAWTHORNE CA
90250-2240
US

IV. Provider business mailing address

2037 VISTA DEL SOL
CHINO HILLS CA
91709-5081
US

V. Phone/Fax

Practice location:
  • Phone: 310-645-0444
  • Fax:
Mailing address:
  • Phone: 714-823-6442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number52560
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: