=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295423564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA THAO NGUYEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2023
-----------------------------------------------------
Last Update Date | 07/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 289 W HUNTINGTON DR STE 204
-----------------------------------------------------
City | ARCADIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91007-3492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-287-3631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1353 BALLISTA AVE
-----------------------------------------------------
City | LA PUENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91744-1609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-346-6108
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA64463
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------