Provider Demographics
NPI:1912040049
Name:PHAN, VAN TUY (PA-C)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:TUY
Last Name:PHAN
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 1:11311 BRIDGEPORT WAY SW STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3096
Mailing Address - Country:US
Mailing Address - Phone:253-985-6490
Mailing Address - Fax:253-985-6488
Practice Address - Street 1:11311 BRIDGEPORT WAY SW STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3096
Practice Address - Country:US
Practice Address - Phone:253-985-6490
Practice Address - Fax:253-985-6488
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004199363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1042154Medicaid
WAP00918654OtherMEDICARE RR
WAG8891647OtherMEDICARE PTAN
WA0262968OtherLNI