Provider Demographics
NPI:1093446221
Name:PHAN, TRUNG TIN
Entity Type:Individual
Prefix:
First Name:TRUNG
Middle Name:TIN
Last Name:PHAN
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 1:2381 EASTWAY RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5543
Mailing Address - Country:US
Mailing Address - Phone:916-719-1709
Mailing Address - Fax:
Practice Address - Street 1:4310 JOHNS CREEK PKWY STE 130
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6092
Practice Address - Country:US
Practice Address - Phone:770-738-9657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist