Provider Demographics
NPI:1972024792
Name:PHAN, SOURIGNA BERNA
Entity Type:Individual
Prefix:MR
First Name:SOURIGNA
Middle Name:BERNA
Last Name:PHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MAGNOLIA AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3123
Mailing Address - Country:US
Mailing Address - Phone:951-905-0454
Mailing Address - Fax:
Practice Address - Street 1:800 MAGNOLIA AVE STE 105
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3123
Practice Address - Country:US
Practice Address - Phone:951-905-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70935225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist