Provider Demographics
NPI:1508249962
Name:NGUYEN, WENDY THU (PA-C)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:THU
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THU
Other - Middle Name:TRANG
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:417 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-3818
Mailing Address - Country:US
Mailing Address - Phone:714-640-3470
Mailing Address - Fax:714-340-3475
Practice Address - Street 1:11942 PARAMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242
Practice Address - Country:US
Practice Address - Phone:562-923-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-02
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA55852363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55852OtherPHYSICIAN ASSISTANT BOARD