Provider Demographics
NPI:1508130311
Name:PHAN, TUNG (PA)
Entity Type:Individual
Prefix:
First Name:TUNG
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 W ANACAPA WAY
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-6154
Mailing Address - Country:US
Mailing Address - Phone:818-317-9291
Mailing Address - Fax:
Practice Address - Street 1:507 S ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-2621
Practice Address - Country:US
Practice Address - Phone:323-268-9191
Practice Address - Fax:323-268-9119
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant