Healthcare Provider Details

I. General information

NPI: 1245889310
Provider Name (Legal Business Name): VICTORIA PHAM RANDAZZO PHD, AG-NP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13522 NEWPORT AVE STE 102
TUSTIN CA
92780-3707
US

IV. Provider business mailing address

7745 E WALNUT RIDGE RD
ORANGE CA
92869-6515
US

V. Phone/Fax

Practice location:
  • Phone: 714-573-8200
  • Fax: 714-573-9401
Mailing address:
  • Phone: 714-743-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95012573
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95012573
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95012573
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: