Active NPI
Jamie Phan, PA-C
- Physician Assistant
- Marina del Rey, CA
National Provider Identifier
1619600194
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 62966
- Practice address
- 4551 Glencoe Ave Ste 145
Marina del Rey, CA 90292-6385 - Phone
- (310) 405-0595
- NPI assigned
- Jul 2, 2022
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | |||
| Physician Assistant | 363A00000X | 62966 | CA | Primary |
Addresses
Primary practice location
4551 Glencoe Ave Ste 145
Marina del Rey, CA 90292-6385
Mailing address
3202 Rosemead PL
Rosemead, CA 91770-2848
Phone (626) 283-1826
Other practice location 1
120 W Hellman Ave
Monterey Park, CA 91754-1209
Phone (626) 282-0261
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: No
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20240613003321 | CA | Practitioner - Physician Assistant | 8224571658 | Reassigns benefits to 2 organizations |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 62966 | CA | MD | Physician Assistant |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Emergency Medicine Physician
- San Gabriel, CA
- NPI 1366021834
CA
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1656720000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1788220800000",
"number": "1619600194",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3202 ROSEMEAD PL",
"city": "ROSEMEAD",
"state": "CA",
"postal_code": "917702848",
"telephone_number": "626-283-1826"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4551 GLENCOE AVE STE 145",
"city": "MARINA DEL REY",
"state": "CA",
"postal_code": "902926385",
"telephone_number": "310-405-0595"
}
],
"practiceLocations": [
{
"address_1": "120 W Hellman Ave",
"address_purpose": "LOCATION",
"city": "Monterey Park",
"state": "CA",
"postal_code": "917541209",
"country_code": "US",
"telephone_number": "626-282-0261",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "PHAN",
"first_name": "JAMIE",
"credential": "PA-C",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2022-07-02",
"last_updated": "2026-09-01",
"certification_date": "2026-09-01",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": null,
"license": null,
"primary": false
},
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "CA",
"license": "62966",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Marina del Rey, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.