Healthcare Provider Details

I. General information

NPI: 1184149064
Provider Name (Legal Business Name): EVELYN LE NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2017
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date: 12/29/2020
Reactivation Date: 01/18/2021

III. Provider practice location address

2552 WALNUT AVE STE 200
TUSTIN CA
92780-6983
US

IV. Provider business mailing address

2552 WALNUT AVE STE 200
TUSTIN CA
92780-6983
US

V. Phone/Fax

Practice location:
  • Phone: 714-406-4461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59228
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: