Provider Demographics
NPI:1083082507
Name:TRUONG, MIA K
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:K
Last Name:TRUONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:
Other - Last Name:KITAJIMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2401 REO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-3025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 REO DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92139-3025
Practice Address - Country:US
Practice Address - Phone:619-479-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002914363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily