Healthcare Provider Details

I. General information

NPI: 1649345695
Provider Name (Legal Business Name): SON PHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8882 HILDRETH LN
STOCKTON CA
95212-9428
US

IV. Provider business mailing address

8882 HILDRETH LANE
STOCKTON CA
95212
US

V. Phone/Fax

Practice location:
  • Phone: 209-825-3616
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: