Basic Information
| Provider Information | |||||||||
| NPI: | 1619571742 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | VINCE | ||||||||
| MiddleName: | VU | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11421 SALINAZ AVE | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928433527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147688325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2575 YORBA LINDA BLVD | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928311615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144497400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2020 | ||||||||
| LastUpdateDate: | 01/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60530 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.