Provider Demographics
NPI:1598991846
Name:NGUYEN, PHUONG H (CRNP)
Entity Type:Individual
Prefix:MS
First Name:PHUONG
Middle Name:H
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MS
Other - First Name:PHUONG
Other - Middle Name:X
Other - Last Name:HO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 62602
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2602
Mailing Address - Country:US
Mailing Address - Phone:410-328-3929
Mailing Address - Fax:410-328-6896
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-3929
Practice Address - Fax:410-328-6896
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR170127363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS053-0067OtherBLUE CROSS/BLUE SHIELD - REGIONAL
MD417523900Medicaid
MD954172-01 & 02OtherBLUE CROSS/BLUE SHIELD
MD954172-01 & 02OtherBLUE CROSS/BLUE SHIELD
MD154004ZAQPMedicare PIN