Provider Demographics
NPI:1104546969
Name:PHAN, THEODORE THIEN
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:THIEN
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 1:52 TRINITY DR
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-5246
Mailing Address - Country:US
Mailing Address - Phone:415-320-2313
Mailing Address - Fax:
Practice Address - Street 1:52 TRINITY DR
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-5246
Practice Address - Country:US
Practice Address - Phone:415-320-2313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-31
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA61808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program