Healthcare Provider Details

I. General information

NPI: 1134657646
Provider Name (Legal Business Name): AUDRIS MEIYIN TIEN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2017
Last Update Date: 12/13/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16405 SAND CANYON AVE STE 270
IRVINE CA
92618-3792
US

IV. Provider business mailing address

16405 SAND CANYON AVE STE 270
IRVINE CA
92618-3792
US

V. Phone/Fax

Practice location:
  • Phone: 949-651-1202
  • Fax: 949-552-9493
Mailing address:
  • Phone: 949-651-1202
  • Fax: 949-552-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: