Basic Information
| Provider Information | |||||||||
| NPI: | 1285129049 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PHAN | ||||||||
| FirstName: | TANYA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16117 OLIVEMILL RD | ||||||||
| Address2: | |||||||||
| City: | LA MIRADA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906383477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626401369 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 S SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269624011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2018 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.