Healthcare Provider Details

I. General information

NPI: 1144711789
Provider Name (Legal Business Name): LAWRENCE IGNACIO GAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 THE CITY DR S
ORANGE CA
92868-3205
US

IV. Provider business mailing address

3305 CITY LIGHTS DR
ALISO VIEJO CA
92656-2633
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-6660
  • Fax:
Mailing address:
  • Phone: 661-678-5629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95061307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: