MEDICARE: PHUONG ANH THI LA P.A.-C

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	363AM0700X	Medical Physician Assistant	PA15064	CA

General Provider Information

NPI Number	:	1891865747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHUONG ANH THI LA P.A.-C

Provider Business Mailing Address
First Line	:	2077 HARBOR BLVD STE 100
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-9384
Country	:	US
Telephone Number	:	949-740-7117
Fax Number	:	949-209-3955

Provider Business Practice Location Address
First Line	:	2077 HARBOR BLVD STE 100
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-9384
Country	:	US
Telephone Number	:	949-740-7117
Fax Number	:	949-209-3955

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	12/15/2025

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