Provider Demographics
NPI:1821587346
Name:NGUYEN, ETHAN D (NP-C)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:D
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13065 W MCDOWELL RD STE A105
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85392-6440
Mailing Address - Country:US
Mailing Address - Phone:623-536-6788
Mailing Address - Fax:623-536-9288
Practice Address - Street 1:13065 W MCDOWELL RD STE A105
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85392-6440
Practice Address - Country:US
Practice Address - Phone:623-536-6788
Practice Address - Fax:235-369-2886
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-10
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF09190130363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty