Basic Information
| Provider Information | |||||||||
| NPI: | 1093269326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | VU | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 SPRUCE AVE | ||||||||
| Address2: | |||||||||
| City: | GALLOWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082054543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094573584 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11772 SORRENTO VALLEY RD | ||||||||
| Address2: | 250 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8006831209 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2016 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT291612 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.