Provider Demographics
NPI:1770583056
Name:TIEN, STACEY CAM (PA - C)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:CAM
Last Name:TIEN
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 W LA VETA AVE STE 850
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4218
Mailing Address - Country:US
Mailing Address - Phone:714-560-4450
Mailing Address - Fax:714-560-4455
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:STE. 850
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4225
Practice Address - Country:US
Practice Address - Phone:714-560-4450
Practice Address - Fax:714-560-4455
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA169522086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00159244OtherRAILROAD MEDICARE
Q00414Medicare UPIN
WPA16952AMedicare PIN