Provider Demographics
NPI:1609128693
Name:TANG, PHUONG NGUYEN (PA)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:NGUYEN
Last Name:TANG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S RAYMOND AVE UNIT 240
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3283
Mailing Address - Country:US
Mailing Address - Phone:626-449-9920
Mailing Address - Fax:844-406-5405
Practice Address - Street 1:630 S RAYMOND AVE UNIT 240
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3283
Practice Address - Country:US
Practice Address - Phone:626-449-9920
Practice Address - Fax:626-578-7366
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant