Provider Demographics
NPI:1063783413
Name:NGUYEN, EVELYN LILLIAN (PA-C)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:LILLIAN
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2192 MARTIN STE 110
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1484
Mailing Address - Country:US
Mailing Address - Phone:949-955-0072
Mailing Address - Fax:949-955-0077
Practice Address - Street 1:2192 MARTIN STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1484
Practice Address - Country:US
Practice Address - Phone:949-955-0072
Practice Address - Fax:949-955-0077
Is Sole Proprietor?:No
Enumeration Date:2012-01-17
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16083363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical