Healthcare Provider Details

I. General information

NPI: 1659798163
Provider Name (Legal Business Name): MINH TAM LUONG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W SANTA ANA BLVD STE 100
SANTA ANA CA
92701-4134
US

IV. Provider business mailing address

200 W. SANTA ANA BLVD; SUITE 100
SANTA ANA CA
92701
US

V. Phone/Fax

Practice location:
  • Phone: 714-347-0300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12544
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: