Provider Demographics
NPI:1457976938
Name:PADILLA-PHU, JERRICK KY XANG (FNP)
Entity Type:Individual
Prefix:
First Name:JERRICK
Middle Name:KY XANG
Last Name:PADILLA-PHU
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8540 PUEBLO DR
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-4346
Mailing Address - Country:US
Mailing Address - Phone:626-688-0996
Mailing Address - Fax:
Practice Address - Street 1:1510 S CENTRAL AVE STE 240
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2570
Practice Address - Country:US
Practice Address - Phone:818-334-5425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA849559163WG0000X
CANP95012638363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice