Provider Demographics
NPI:1073596243
Name:NGUYEN, KIMYA-ANHCINA LAN (DO)
Entity Type:Individual
Prefix:DR
First Name:KIMYA-ANHCINA
Middle Name:LAN
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIM-ANH
Other - Middle Name:THI
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2700 SE STRATUS AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-8872
Mailing Address - Country:US
Mailing Address - Phone:503-434-6688
Mailing Address - Fax:
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-8872
Practice Address - Country:US
Practice Address - Phone:503-434-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25231207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028815Medicaid
OR130195Medicare ID - Type Unspecified
I05570Medicare UPIN