Provider Demographics
NPI:1407140098
Name:NGUYEN, TAN D (RPA)
Entity Type:Individual
Prefix:
First Name:TAN
Middle Name:D
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 CEDAR WOODS TRL
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7769
Mailing Address - Country:US
Mailing Address - Phone:541-852-7719
Mailing Address - Fax:
Practice Address - Street 1:97 HEFNER ST
Practice Address - Street 2:SUITE 202
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8268
Practice Address - Country:US
Practice Address - Phone:706-635-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR912827243U00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant