1649864604 NPI number — MS. TRI NGOC DAM NURSE PRACTITIONER

Table of content: MS. TRI NGOC DAM NURSE PRACTITIONER (NPI 1649864604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649864604 NPI number — MS. TRI NGOC DAM NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAM
Provider First Name:
TRI
Provider Middle Name:
NGOC
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649864604
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20449 TIMES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYWARD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94541-3745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-304-4810
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
87 N 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95112-5423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-279-1180
Provider Business Practice Location Address Fax Number:
408-279-6745
Provider Enumeration Date:
02/21/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  95006901 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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