Provider Demographics
NPI:1992191480
Name:NGUYEN, PHUONG THANH (MEDICAL PROVIDER)
Entity Type:Individual
Prefix:
First Name:PHUONG
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:MEDICAL PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11712 BANNER DR
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-2707
Mailing Address - Country:US
Mailing Address - Phone:714-785-4111
Mailing Address - Fax:
Practice Address - Street 1:11712 BANNER DR
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-2707
Practice Address - Country:US
Practice Address - Phone:714-785-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital