Healthcare Provider Details

I. General information

NPI: 1962065920
Provider Name (Legal Business Name): ANPHONG NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAS TABLAS RD
TEMPLETON CA
93465-9704
US

IV. Provider business mailing address

1917 BELMAR WAY
UPLAND CA
91784-1510
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA190579
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: