Healthcare Provider Details

I. General information

NPI: 1710875554
Provider Name (Legal Business Name): HOANG-LAN PHAN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 FOREST AVE # 138
PACIFIC GROVE CA
93950-5105
US

IV. Provider business mailing address

1120 FOREST AVE # 138
PACIFIC GROVE CA
93950-5105
US

V. Phone/Fax

Practice location:
  • Phone: 831-200-9651
  • Fax:
Mailing address:
  • Phone: 831-200-9651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95036308
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95159511
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: