Provider Demographics
NPI:1316581416
Name:PHAN, ANNIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10787 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3828
Mailing Address - Country:US
Mailing Address - Phone:909-982-7741
Mailing Address - Fax:
Practice Address - Street 1:10787 LAUREL ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3828
Practice Address - Country:US
Practice Address - Phone:909-982-7741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty