Provider Demographics
NPI:1083339097
Name:NGUYEN, RYAN PHAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:PHAN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1947 GALILEO CT STE 101
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4882
Mailing Address - Country:US
Mailing Address - Phone:530-220-1450
Mailing Address - Fax:
Practice Address - Street 1:1947 GALILEO CT STE 101
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-4882
Practice Address - Country:US
Practice Address - Phone:530-220-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY7875869106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician