Provider Demographics
NPI:1144685504
Name:TRIEU, ERICSSON (PA-C)
Entity type:Individual
Prefix:
First Name:ERICSSON
Middle Name:
Last Name:TRIEU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12456 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90602-1005
Mailing Address - Country:US
Mailing Address - Phone:562-758-6600
Mailing Address - Fax:
Practice Address - Street 1:12456 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1005
Practice Address - Country:US
Practice Address - Phone:562-758-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1692363A00000X
CA54702363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1144685504Medicaid
NV1144685504Medicaid