Provider Demographics
NPI:1619962552
Name:TRUONG, KHANH YEN (MD)
Entity type:Individual
Prefix:DR
First Name:KHANH
Middle Name:YEN
Last Name:TRUONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KHANH
Other - Middle Name:YEN
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1101 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6341
Mailing Address - Country:US
Mailing Address - Phone:707-527-9517
Mailing Address - Fax:707-527-9913
Practice Address - Street 1:196 WIKIUP DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-7773
Practice Address - Country:US
Practice Address - Phone:075-279-5177
Practice Address - Fax:707-527-9913
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53920207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH36649Medicare UPIN