Healthcare Provider Details

I. General information

NPI: 1558130310
Provider Name (Legal Business Name): SANG HOANG PHUOC PHAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 TAYLOR RD
CHESAPEAKE VA
23321-2201
US

IV. Provider business mailing address

825 FAIRFAX AVE
NORFOLK VA
23507-1912
US

V. Phone/Fax

Practice location:
  • Phone: 757-215-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010220
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: