Provider Demographics
NPI:1164417010
Name:NGUYEN, KHANH Q (PA C)
Entity Type:Individual
Prefix:
First Name:KHANH
Middle Name:Q
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4059
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4059
Mailing Address - Country:US
Mailing Address - Phone:973-826-8291
Mailing Address - Fax:
Practice Address - Street 1:4215 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-2206
Practice Address - Country:US
Practice Address - Phone:407-539-2000
Practice Address - Fax:407-398-0050
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102312363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1470YOtherMEDICARE PTAN - QSS SCS
FL291549900Medicaid
FLHF826AOtherMEDICARE PTAN - GRP QSS SCS
FL291549900Medicaid
FLU1470YOtherMEDICARE PTAN - QSS SCS