Provider Demographics
NPI:1578523874
Name:NGUYEN, PHUONG M (MD)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:M
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:MD
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1782
Mailing Address - Fax:704-384-1783
Practice Address - Street 1:801 VASSAR DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2725
Practice Address - Country:US
Practice Address - Phone:505-248-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200501586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902582Medicaid
NM45752061Medicaid
NC2049236Medicare PIN
BN6020274OtherFEDERAL DEA
2049236Medicare ID - Type Unspecified