Healthcare Provider Details

I. General information

NPI: 1962775684
Provider Name (Legal Business Name): KIMBERLY VI NGUYEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18800 MAIN ST STE 103
HUNTINGTON BEACH CA
92648
US

IV. Provider business mailing address

18800 MAIN ST STE 103
HUNTINGTON BEACH CA
92648-1717
US

V. Phone/Fax

Practice location:
  • Phone: 714-842-8100
  • Fax: 714-842-8181
Mailing address:
  • Phone: 714-842-8100
  • Fax: 714-842-8181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: