Provider Demographics
NPI:1962853135
Name:NGUYEN, PHUOC NAM VAN (DO)
Entity Type:Individual
Prefix:
First Name:PHUOC NAM
Middle Name:VAN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-5334
Mailing Address - Country:US
Mailing Address - Phone:714-383-0793
Mailing Address - Fax:
Practice Address - Street 1:5515 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2603
Practice Address - Country:US
Practice Address - Phone:814-868-8206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT017279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine