Healthcare Provider Details

I. General information

NPI: 1609128693
Provider Name (Legal Business Name): PHUONG NGUYEN TANG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 S RAYMOND AVE UNIT 240
PASADENA CA
91105-3283
US

IV. Provider business mailing address

630 S RAYMOND AVE UNIT 240
PASADENA CA
91105-3283
US

V. Phone/Fax

Practice location:
  • Phone: 626-449-9920
  • Fax: 626-578-7366
Mailing address:
  • Phone: 626-449-9920
  • Fax: 844-406-5405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22588
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: