Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | A70331 | CA |
Y | 207NS0135X | Procedural Dermatology | A70331 | CA |
NPI | 1144273491 |
---|---|
Provider Name | Tan Khac Nguyen |
First Address | Upland, CA 91786-4979 |
Second Address | Upland, CA 91786-4979 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/05/2006 |
Last Update Date | 08/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H21605 | (02) | CA |
P00614352 | RAILLROAD MEDICARE (01) | CA |