Provider Demographics
NPI:1760155857
Name:NGUYEN, DOMINIC ANH-PHONG (PA-C)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:ANH-PHONG
Last Name:NGUYEN
Suffix:
Gender:M
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 1:10907 DOUD ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-3146
Mailing Address - Country:US
Mailing Address - Phone:281-919-6912
Mailing Address - Fax:
Practice Address - Street 1:9130 HIGHWAY 6 S
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-6376
Practice Address - Country:US
Practice Address - Phone:281-564-3300
Practice Address - Fax:281-564-2777
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant