Provider Demographics
NPI:1609508597
Name:NGUYEN, VAN (PA-C)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VIVIENNE
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:6803 OAKLEY ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-3914
Mailing Address - Country:US
Mailing Address - Phone:267-265-9443
Mailing Address - Fax:
Practice Address - Street 1:1420 LOCUST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4223
Practice Address - Country:US
Practice Address - Phone:215-800-1909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant