Healthcare Provider Details

I. General information

NPI: 1265077556
Provider Name (Legal Business Name): KATHY PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 IRVINE BLVD
TUSTIN CA
92780-3804
US

IV. Provider business mailing address

6591 LA PAT CT APT A
WESTMINSTER CA
92683-3647
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-8878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA58387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: