MEDICARE: PHUONG KIM PHAN

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	390200000X	Student in an Organized Health Care Education/Training Program	51056	CA

General Provider Information

NPI Number	:	1619825395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHUONG KIM PHAN

Provider Business Mailing Address
First Line	:	2468 63RD AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94605-1411
Country	:	US
Telephone Number	:	510-857-7299
Fax Number	:

Provider Business Practice Location Address
First Line	:	2468 63RD AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94605-1411
Country	:	US
Telephone Number	:	510-857-7299
Fax Number	:

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

Provider Enumeration Date	:	03/19/2026
Last Update Date	:	03/19/2026

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Directions to “ PHUONG KIM PHAN ” Practice Location

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