Provider Demographics
NPI:1821256942
Name:NGUYEN, NATHAN PHUCKHAC (MD,)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:PHUCKHAC
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:DR
Other - First Name:PHUC
Other - Middle Name:KHAC
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1403 VALHALLA DR
Mailing Address - Street 2:
Mailing Address - City:WHARTON
Mailing Address - State:TX
Mailing Address - Zip Code:77488-9218
Mailing Address - Country:US
Mailing Address - Phone:979-532-2000
Mailing Address - Fax:979-532-2008
Practice Address - Street 1:1403 VALHALLA DR
Practice Address - Street 2:
Practice Address - City:WHARTON
Practice Address - State:TX
Practice Address - Zip Code:77488-9218
Practice Address - Country:US
Practice Address - Phone:979-532-2000
Practice Address - Fax:979-532-2008
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0318207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN0318OtherTXLIC
TXX0159013OtherDPS
TXX0159013OtherDPS