Basic Information
Provider Information | |||||||||
NPI: | 1033262787 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VU | ||||||||
FirstName: | LAN | ||||||||
MiddleName: | PHAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PHAN | ||||||||
OtherFirstName: | LAN | ||||||||
OtherMiddleName: | KIM | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 845347 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752845347 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146454673 | ||||||||
FaxNumber: | 2146487084 | ||||||||
Practice Location | |||||||||
Address1: | 5323 HARRY HINES BLVD | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753907201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2146454673 | ||||||||
FaxNumber: | 2146487084 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2007 | ||||||||
LastUpdateDate: | 03/21/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA01782 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 192264301 | 05 | TX |   | MEDICAID | 500002438 | 01 | TX | RAILROAD MEDICARE | OTHER | 87N175 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |