Provider Demographics
NPI:1093203838
Name:HUYNH, LONG BAO
Entity Type:Individual
Prefix:
First Name:LONG
Middle Name:BAO
Last Name:HUYNH
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 1:12592 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92845-2602
Mailing Address - Country:US
Mailing Address - Phone:714-230-9458
Mailing Address - Fax:
Practice Address - Street 1:9353 BOLSA AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-5951
Practice Address - Country:US
Practice Address - Phone:800-641-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008947363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily