Provider Demographics
NPI:1073943098
Name:NGUYEN, TIN (PA)
Entity Type:Individual
Prefix:
First Name:TIN
Middle Name:
Last Name:NGUYEN
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 1:1300 W TERRELL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2822
Mailing Address - Country:US
Mailing Address - Phone:817-820-4280
Mailing Address - Fax:817-820-4281
Practice Address - Street 1:1300 W TERRELL AVE STE 300
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2822
Practice Address - Country:US
Practice Address - Phone:817-820-4280
Practice Address - Fax:817-820-4281
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX322118YKPWMedicare PIN