Provider Demographics
NPI:1164885133
Name:NGUYEN, PHONG THANH (NP)
Entity Type:Individual
Prefix:
First Name:PHONG
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 GERONIMO DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-1836
Mailing Address - Country:US
Mailing Address - Phone:915-591-2704
Mailing Address - Fax:915-225-0413
Practice Address - Street 1:6501 N MESA ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-4435
Practice Address - Country:US
Practice Address - Phone:915-585-6211
Practice Address - Fax:915-598-3946
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130529363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily