Provider Demographics
NPI:1295229235
Name:NGUYEN, AN TAM THI (PA-C)
Entity Type:Individual
Prefix:MS
First Name:AN TAM
Middle Name:THI
Last Name:NGUYEN
Suffix:
Gender:F
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 1:901 SAN BERNARDINO RD STE 102
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4988
Mailing Address - Country:US
Mailing Address - Phone:909-579-6721
Mailing Address - Fax:909-579-6737
Practice Address - Street 1:901 SAN BERNARDINO RD STE 102
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4988
Practice Address - Country:US
Practice Address - Phone:909-579-6721
Practice Address - Fax:909-579-6737
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1382363AS0400X
CA55765363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical