Provider Demographics
NPI:1093269326
Name:PHAN, DIANE VU (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:VU
Last Name:PHAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-4543
Mailing Address - Country:US
Mailing Address - Phone:609-457-3584
Mailing Address - Fax:
Practice Address - Street 1:11772 SORRENTO VALLEY RD
Practice Address - Street 2:250
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1015
Practice Address - Country:US
Practice Address - Phone:800-683-1209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist