Healthcare Provider Details

I. General information

NPI: 1003635277
Provider Name (Legal Business Name): TAYLOR THANH-TAM NGUYEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 AVOCADO AVE STE 802
NEWPORT BEACH CA
92660-7709
US

IV. Provider business mailing address

17260 SANTA LUCIA ST
FOUNTAIN VALLEY CA
92708-3116
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-1212
  • Fax: 949-620-1222
Mailing address:
  • Phone: 714-785-1999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number65337
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: