Provider Demographics
NPI:1578928321
Name:PHAN, THANHTRUC HOANG (FNP-C)
Entity Type:Individual
Prefix:
First Name:THANHTRUC
Middle Name:HOANG
Last Name:PHAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:TRUC
Other - Middle Name:
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:5525 GROSSMONT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3009
Mailing Address - Country:US
Mailing Address - Phone:858-499-2711
Mailing Address - Fax:
Practice Address - Street 1:5525 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3009
Practice Address - Country:US
Practice Address - Phone:858-499-2711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily