Healthcare Provider Details

I. General information

NPI: 1821493230
Provider Name (Legal Business Name): JEAN HUYNH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11725 STATE AVE. SUITE 100
RIVERSIDE CA
92505
US

IV. Provider business mailing address

11725 STATE AVENUE 100
RIVERSIDE CA
92505
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-1700
  • Fax: 951-352-9117
Mailing address:
  • Phone: 951-352-1700
  • Fax: 951-352-9117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5614
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number53716
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: