Provider Demographics
NPI:1275117418
Name:PHAN, NGAN NGOC (NA)
Entity Type:Individual
Prefix:MISS
First Name:NGAN
Middle Name:NGOC
Last Name:PHAN
Suffix:
Gender:F
Credentials:NA
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:NA
Other - Last Name:NA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NA
Mailing Address - Street 1:513 N 48TH ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-3623
Mailing Address - Country:US
Mailing Address - Phone:717-343-5533
Mailing Address - Fax:
Practice Address - Street 1:4300 LONDONDERRY RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5317
Practice Address - Country:US
Practice Address - Phone:717-920-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5402323769Medicaid