Provider Demographics
NPI:1417699869
Name:PHAM, NINA NGUYEN
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:NGUYEN
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 S STATE COLLEGE BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-5814
Mailing Address - Country:US
Mailing Address - Phone:057-193-7008
Mailing Address - Fax:805-413-9099
Practice Address - Street 1:10737 CAMINO RUIZ STE 235
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-2375
Practice Address - Country:US
Practice Address - Phone:844-200-2426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020179363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily