Healthcare Provider Details

I. General information

NPI: 1861119356
Provider Name (Legal Business Name): NICOLE TIEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 LINCOLN BLVD STE 100
SANTA MONICA CA
90405-1320
US

IV. Provider business mailing address

2221 LINCOLN BLVD STE 100
SANTA MONICA CA
90405-1320
US

V. Phone/Fax

Practice location:
  • Phone: 310-392-1111
  • Fax: 310-392-1101
Mailing address:
  • Phone: 310-392-1111
  • Fax: 310-392-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number61690
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: