Provider Demographics
NPI:1760498919
Name:TRUONG, THERESA H (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:H
Last Name:TRUONG
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 1:415 W VALLEY BLVD
Mailing Address - Street 2:C
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3728
Mailing Address - Country:US
Mailing Address - Phone:626-943-9240
Mailing Address - Fax:626-943-9242
Practice Address - Street 1:415 W VALLEY BLVD
Practice Address - Street 2:C
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3728
Practice Address - Country:US
Practice Address - Phone:626-943-9240
Practice Address - Fax:626-943-9242
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15200363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical