Healthcare Provider Details

I. General information

NPI: 1457829970
Provider Name (Legal Business Name): JIMMY MINH HOANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E FOOTHILL BLVD STE C
POMONA CA
91767-1200
US

IV. Provider business mailing address

218 PALOS VERDES DR
SANTA ANA CA
92704-2477
US

V. Phone/Fax

Practice location:
  • Phone: 909-398-4895
  • Fax:
Mailing address:
  • Phone: 503-453-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57480
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: