Healthcare Provider Details

I. General information

NPI: 1669050266
Provider Name (Legal Business Name): MINH ANH PHAN STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST GME OFFICE WESTERLY SUITE C
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11234 ANDERSON STREET GME OFFICE WESTERLY SUITE C
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4174
  • Fax:
Mailing address:
  • Phone: 909-558-4174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22617
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: