Basic Information
| Provider Information | |||||||||
| NPI: | 1639514144 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASEN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | PHAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PHAM | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 7087 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928637087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145715000 | ||||||||
| FaxNumber: | 7145715055 | ||||||||
| Practice Location | |||||||||
| Address1: | 30230 RANCHO VIEJO RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494434303 | ||||||||
| FaxNumber: | 9494434033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2013 | ||||||||
| LastUpdateDate: | 04/30/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | A141493 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | A141493 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.