Provider Demographics
NPI:1003199910
Name:NGUYEN, AUTUMN (PAC)
Entity Type:Individual
Prefix:MS
First Name:AUTUMN
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 PARK ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-1445
Mailing Address - Country:US
Mailing Address - Phone:570-253-8140
Mailing Address - Fax:570-253-8633
Practice Address - Street 1:38935 ANN ARBOR RD
Practice Address - Street 2:CREDENTIALING/PAYER ENROLLMENT DEPT
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3397
Practice Address - Country:US
Practice Address - Phone:734-632-0175
Practice Address - Fax:734-805-0489
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA055123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA055123OtherSTATE LICENSE
PAPENDINGOtherCAQH