Provider Demographics
NPI:1134363682
Name:NGUYEN, DUC THANH (PA)
Entity type:Individual
Prefix:
First Name:DUC
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LANSING ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1983
Mailing Address - Country:US
Mailing Address - Phone:315-255-7576
Mailing Address - Fax:315-702-8393
Practice Address - Street 1:17 LANSING ST STE 302
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1983
Practice Address - Country:US
Practice Address - Phone:315-567-0540
Practice Address - Fax:315-567-0334
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23 013181363A00000X
NY013181363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03142665Medicaid