Provider Demographics
NPI:1639528110
Name:PHUNG, AIVI DOLAN (PA-C)
Entity Type:Individual
Prefix:
First Name:AIVI
Middle Name:DOLAN
Last Name:PHUNG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6973 LINDA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-6342
Mailing Address - Country:US
Mailing Address - Phone:858-279-0925
Mailing Address - Fax:858-633-4680
Practice Address - Street 1:6973 LINDA VISTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-6342
Practice Address - Country:US
Practice Address - Phone:858-279-0925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA53902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant