Provider Demographics
NPI:1659809275
Name:NGUYEN, MY THANH (PA-C)
Entity Type:Individual
Prefix:
First Name:MY
Middle Name:THANH
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 1:2616 GLEN COTSWOLD CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-2544
Mailing Address - Country:US
Mailing Address - Phone:408-858-6458
Mailing Address - Fax:
Practice Address - Street 1:2331 MONTPELIER DR STE B
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1673
Practice Address - Country:US
Practice Address - Phone:408-347-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant