Healthcare Provider Details

I. General information

NPI: 1396082202
Provider Name (Legal Business Name): PHON H VUONG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2013
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31852 COAST HWY SUITE 300
LAGUNA BEACH CA
92651-6764
US

IV. Provider business mailing address

31852 COAST HWY SUITE 300
LAGUNA BEACH CA
92651-6764
US

V. Phone/Fax

Practice location:
  • Phone: 949-499-1389
  • Fax: 949-499-5689
Mailing address:
  • Phone: 949-499-1389
  • Fax: 949-499-5689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: