Basic Information
| Provider Information | |||||||||
| NPI: | 1639617723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUYEN | ||||||||
| FirstName: | JADE | ||||||||
| MiddleName: | BAO-TRAN | ||||||||
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| OtherLastName: | LAM | ||||||||
| OtherFirstName: | JADE | ||||||||
| OtherMiddleName: | BAO-TRAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 514 WHITESAGE RD | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920787920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608051175 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1901 CARNEGIE AVE STE 1C | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927055504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148488319 | ||||||||
| FaxNumber: | 7145966274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2017 | ||||||||
| LastUpdateDate: | 02/08/2017 | ||||||||
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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 | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.