Provider Demographics
NPI:1518931476
Name:NGUYEN, NGOC DUNG (PA-C)
Entity Type:Individual
Prefix:
First Name:NGOC
Middle Name:DUNG
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-3700
Mailing Address - Fax:323-865-0120
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:SUITE 7416
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0112
Practice Address - Country:US
Practice Address - Phone:323-865-3750
Practice Address - Fax:323-865-0120
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3147363AS0400X
CAPA15253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP64294Medicare UPIN
102777Medicare ID - Type Unspecified