Provider Demographics
NPI:1689377897
Name:CHUONG, TRI THANH (NP)
Entity Type:Individual
Prefix:
First Name:TRI
Middle Name:THANH
Last Name:CHUONG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17872 GILLETTE AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6573
Mailing Address - Country:US
Mailing Address - Phone:949-535-4755
Mailing Address - Fax:
Practice Address - Street 1:17872 GILLETTE AVE STE 240
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6573
Practice Address - Country:US
Practice Address - Phone:949-535-4755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95022126363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily