Provider Demographics
NPI:1508393406
Name:NGUYEN, KIM ANH (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ANH
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 N HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-3418
Mailing Address - Country:US
Mailing Address - Phone:757-277-8870
Mailing Address - Fax:
Practice Address - Street 1:640 S STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3530
Practice Address - Country:US
Practice Address - Phone:302-674-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA005965363A00000X
PAMA063283363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant