Healthcare Provider Details

I. General information

NPI: 1770583056
Provider Name (Legal Business Name): STACEY CAM TIEN P.A. - C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W LA VETA AVE STE. 850
ORANGE CA
92868-4225
US

IV. Provider business mailing address

1140 W LA VETA AVE STE 850
ORANGE CA
92868-4218
US

V. Phone/Fax

Practice location:
  • Phone: 714-560-4450
  • Fax: 714-560-4455
Mailing address:
  • Phone: 714-560-4450
  • Fax: 714-560-4455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberPA16952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: