Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207NS0135X | Procedural Dermatology | G77748 | CA |
NPI | 1104828508 |
---|---|
Provider Name | Dr. Ethan-Quan H Nguyen |
First Address | Riverside, CA 92501-3518 |
Second Address | Riverside, CA 92501-3518 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2005 |
Last Update Date | 01/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
030454716 | TAX ID (01) | CA |