Provider Demographics
NPI:1154188738
Name:PHUNG, PHILLIP NGUYEN (FNP)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:NGUYEN
Last Name:PHUNG
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5885 INDIAN POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-5764
Mailing Address - Country:US
Mailing Address - Phone:805-300-4521
Mailing Address - Fax:
Practice Address - Street 1:5885 INDIAN POINTE DR
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-5764
Practice Address - Country:US
Practice Address - Phone:805-300-4521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily