Healthcare Provider Details

I. General information

NPI: 1134501034
Provider Name (Legal Business Name): MR. ANH TUAN NGUYEN PHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2015
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E VIRGINIA ST STE 100
SAN JOSE CA
95112-5865
US

IV. Provider business mailing address

76 MARIAN LN
SAN JOSE CA
95127-2023
US

V. Phone/Fax

Practice location:
  • Phone: 408-918-2618
  • Fax: 408-579-6143
Mailing address:
  • Phone: 408-724-7877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: