Provider Demographics
NPI:1104218494
Name:NGUYEN, MY PHUONG PHAM (NP)
Entity Type:Individual
Prefix:
First Name:MY PHUONG PHAM
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PHUONG
Other - Middle Name:MY
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1310 W STEWART DR
Mailing Address - Street 2:STE 410
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3854
Mailing Address - Country:US
Mailing Address - Phone:714-639-9401
Mailing Address - Fax:
Practice Address - Street 1:1010 W LA VETA AVE
Practice Address - Street 2:STE 750
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4300
Practice Address - Country:US
Practice Address - Phone:714-361-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912919804OtherTYPE 2 NPI
CA95001664OtherNP LICENSE & FURNISHING NUMBER
CA767746OtherRN LICENSE
CA767746OtherRN LICENSE
CACB230484Medicare PIN