Provider Demographics
NPI:1083942817
Name:NGUYEN, LISA (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 FLOWER MOUND RD
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-3503
Mailing Address - Country:US
Mailing Address - Phone:972-874-8421
Mailing Address - Fax:972-874-8467
Practice Address - Street 1:1100 FLOWER MOUND RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-3503
Practice Address - Country:US
Practice Address - Phone:972-874-8421
Practice Address - Fax:972-874-8467
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-07
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06372363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA06372OtherSTATE LICENSE