Provider Demographics
NPI:1922696129
Name:LY, PHUONG
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11616 LAKE UNDERHILL RD STE 215
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-4465
Mailing Address - Country:US
Mailing Address - Phone:407-482-7788
Mailing Address - Fax:407-482-8698
Practice Address - Street 1:1507 S HIAWASSEE RD STE 107
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5706
Practice Address - Country:US
Practice Address - Phone:407-601-5308
Practice Address - Fax:407-482-8698
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant