Provider Demographics
NPI:1194303958
Name:NGUYEN, THEODORA PHAM
Entity type:Individual
Prefix:
First Name:THEODORA
Middle Name:PHAM
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4950 SAN BERNARDINO ST STE 202
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2328
Mailing Address - Country:US
Mailing Address - Phone:909-621-7647
Mailing Address - Fax:877-887-5774
Practice Address - Street 1:4950 SAN BERNARDINO ST STE 202
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2328
Practice Address - Country:US
Practice Address - Phone:909-621-7647
Practice Address - Fax:877-887-5774
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
CAPA59501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical