Provider Demographics
NPI:1659959898
Name:PHANG, CHRISTINE JIA EN
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:JIA EN
Last Name:PHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 COURT ST APT 306
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2972
Mailing Address - Country:US
Mailing Address - Phone:412-539-6047
Mailing Address - Fax:
Practice Address - Street 1:1500 PETALUMA BLVD S
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5545
Practice Address - Country:US
Practice Address - Phone:707-765-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program