Dr. Jimmy Phan Medical Corporation

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

Legal business name

DR. JIMMY PHAN MEDICAL CORPORATION

Practice address

425 Diamond Dr Ste 103
Lake Elsinore, CA 92530-4495

Phone

(951) 981-3122

NPI assigned

Dec 15, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jimmy Ninh Hoang Phan, M.D.NPI 1770928962

Title

Ceo

Phone

(714) 232-9493

Specialties & licenses 1

Addresses

Other names 1

• Lake ELsinore Pediatrics Doing business as

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jimmy Ninh Hoang Phan, M.D.

  • Pediatrics Physician
  • Lake Elsinore, CA
  • NPI 1770928962
  NPD Authorized official
• Shayla Casanova, FNP-BC

  • Family Nurse Practitioner
  • Lake Elsinore, CA
  • NPI 1710664990
  NPD (past)
• Sherrel Parnell, FNP-C

  • Family Nurse Practitioner
  • Lake Elsinore, CA
  • NPI 1366239659
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1639526400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1643241600000",
    "number": "1144989385",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "425 DIAMOND DR STE 103",
            "city": "LAKE ELSINORE",
            "state": "CA",
            "postal_code": "925304495",
            "telephone_number": "951-981-3122"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "425 DIAMOND DR STE 103",
            "city": "LAKE ELSINORE",
            "state": "CA",
            "postal_code": "925304495",
            "telephone_number": "951-981-3122"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DR. JIMMY PHAN MEDICAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-12-15",
        "last_updated": "2022-01-27",
        "certification_date": "2022-01-27",
        "status": "A",
        "authorized_official_last_name": "PHAN",
        "authorized_official_first_name": "JIMMY",
        "authorized_official_middle_name": "NINH HOANG",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "714-232-9493",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lake ELsinore Pediatrics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Blake Eddow, PT
• Jennifer Edquist, RN, MSN, PHN, SNSC

• Pediatrics Physician in Lake Elsinore, CA
• Providers in Lake Elsinore, CA by specialty
• Pediatrics Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.