Provider Demographics
NPI:1497171565
Name:NGUYEN, MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
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 1:8335 FREEDOM CROSSING TRL APT 2506
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-1202
Mailing Address - Country:US
Mailing Address - Phone:405-819-3774
Mailing Address - Fax:
Practice Address - Street 1:9826 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5438
Practice Address - Country:US
Practice Address - Phone:904-262-9444
Practice Address - Fax:904-262-3750
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015824300Medicaid
FLHZ179UMedicare PIN