Provider Demographics
NPI:1588363873
Name:PHAN, ALLYSON TRAM (FNP)
Entity type:Individual
Prefix:
First Name:ALLYSON
Middle Name:TRAM
Last Name:PHAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ALLYSON
Other - Middle Name:TRAM
Other - Last Name:HOANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:14001 NEWPORT AVE STE F
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7830
Mailing Address - Country:US
Mailing Address - Phone:714-248-5488
Mailing Address - Fax:
Practice Address - Street 1:14001 NEWPORT AVE STE F
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7830
Practice Address - Country:US
Practice Address - Phone:714-248-5488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty