Provider Demographics
NPI:1013472661
Name:NGUYEN, JONATHAN BAOSON
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BAOSON
Last Name:NGUYEN
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 1:1540 W EDITHIA AVE
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-1305
Mailing Address - Country:US
Mailing Address - Phone:714-209-5701
Mailing Address - Fax:
Practice Address - Street 1:12540 MCCANN DR
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3337
Practice Address - Country:US
Practice Address - Phone:714-664-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72361183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist