Provider Demographics
NPI:1477248789
Name:PHAN, BAO (ATC)
Entity Type:Individual
Prefix:
First Name:BAO
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 45TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4808
Mailing Address - Country:US
Mailing Address - Phone:202-603-4768
Mailing Address - Fax:202-603-4768
Practice Address - Street 1:2335 CHATSWORTH BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-1646
Practice Address - Country:US
Practice Address - Phone:202-603-4768
Practice Address - Fax:202-603-4768
Is Sole Proprietor?:No
Enumeration Date:2023-04-11
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program