Provider Demographics
NPI:1629791199
Name:NGUYEN, MISHA (PA-C)
Entity Type:Individual
Prefix:
First Name:MISHA
Middle Name:
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 1:8522 WINDFORD WAY
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-5931
Mailing Address - Country:US
Mailing Address - Phone:916-627-5062
Mailing Address - Fax:
Practice Address - Street 1:4200 DOUGLAS BLVD
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-5902
Practice Address - Country:US
Practice Address - Phone:916-461-9004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61674363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant