Provider Demographics
NPI:1740700350
Name:PHAN, RICKY NGUYEN (ACNP)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:NGUYEN
Last Name:PHAN
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:NGUYEN
Other - Middle Name:HONG
Other - Last Name:PHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13591 BOWEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-3223
Mailing Address - Country:US
Mailing Address - Phone:714-261-7813
Mailing Address - Fax:
Practice Address - Street 1:13591 BOWEN ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-3223
Practice Address - Country:US
Practice Address - Phone:714-261-7813
Practice Address - Fax:714-261-7813
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-24
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006779363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care