Provider Demographics
NPI:1033665864
Name:NGUYEN, THAO (NPP)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1070 MIDDLE COUNTRY RD STE 7-271
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2580
Mailing Address - Country:US
Mailing Address - Phone:516-398-6691
Mailing Address - Fax:631-318-6443
Practice Address - Street 1:12 FAIRWOOD LN
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-3336
Practice Address - Country:US
Practice Address - Phone:631-318-4004
Practice Address - Fax:631-318-6443
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401940-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04591291Medicaid