Provider Demographics
NPI:1063014298
Name:HOANG, BAO XUAN (PA)
Entity Type:Individual
Prefix:
First Name:BAO
Middle Name:XUAN
Last Name:HOANG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1049 S STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1049 S STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6135
Practice Address - Country:US
Practice Address - Phone:561-250-7047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9113574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9113574OtherFL DEPARTMENT OF HEALTH PA LICENSE