MEDICARE: KEVIN SAM VUONG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA58669	CA

General Provider Information

NPI Number	:	1124627435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN SAM VUONG

Provider Business Mailing Address
First Line	:	1127 WILSHIRE BLVD STE 1618
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4007
Country	:	US
Telephone Number	:	213-977-1176
Fax Number	:

Provider Business Practice Location Address
First Line	:	1127 WILSHIRE BLVD STE 1618
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4007
Country	:	US
Telephone Number	:	213-977-1176
Fax Number	:	213-977-0668

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2020
Last Update Date	:	11/18/2024

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