Healthcare Provider Details

I. General information

NPI: 1912466269
Provider Name (Legal Business Name): ANGIE NAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2019
Last Update Date: 03/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 W POPLAR AVE
PORTERVILLE CA
93257-5839
US

IV. Provider business mailing address

187 FAIRGROUNDS DR
SACRAMENTO CA
95817-2407
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 909-702-0083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number56581
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: