Provider Demographics
NPI:1396328332
Name:LE, PHUONG TRAM NGOC
Entity type:Individual
Prefix:
First Name:PHUONG TRAM
Middle Name:NGOC
Last Name:LE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRAM
Other - Middle Name:
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13001 E 17TH PL RM E7019
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1971 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3917
Practice Address - Country:US
Practice Address - Phone:888-959-5192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program