Healthcare Provider Details

I. General information

NPI: 1124627435
Provider Name (Legal Business Name): KEVIN SAM VUONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 WILSHIRE BLVD STE 1618
LOS ANGELES CA
90017-4007
US

IV. Provider business mailing address

1127 WILSHIRE BLVD STE 1618
LOS ANGELES CA
90017-4007
US

V. Phone/Fax

Practice location:
  • Phone: 213-977-1176
  • Fax: 213-977-0668
Mailing address:
  • Phone: 213-977-1176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA58669
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: