Healthcare Provider Details

I. General information

NPI: 1720542665
Provider Name (Legal Business Name): JAYLENE THIEN NGUYEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W 1ST ST STE 101
SANTA ANA CA
92703-3757
US

IV. Provider business mailing address

1401 W 1ST ST STE 101
SANTA ANA CA
92703-3757
US

V. Phone/Fax

Practice location:
  • Phone: 714-542-9700
  • Fax: 714-542-9708
Mailing address:
  • Phone: 714-542-9700
  • Fax: 714-542-9708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA56476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: