Provider Demographics
NPI:1043590250
Name:NGUYEN, KAITLYN PHUONG (PAC)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:PHUONG
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 1:17220 NEWHOPE ST
Mailing Address - Street 2:#125
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4272
Mailing Address - Country:US
Mailing Address - Phone:714-435-0600
Mailing Address - Fax:
Practice Address - Street 1:17220 NEWHOPE ST
Practice Address - Street 2:#125
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4272
Practice Address - Country:US
Practice Address - Phone:714-435-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21641363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical