Provider Demographics
NPI:1134795263
Name:DUONG, MINH QUANG (PTA)
Entity type:Individual
Prefix:
First Name:MINH
Middle Name:QUANG
Last Name:DUONG
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6781 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5740
Mailing Address - Country:US
Mailing Address - Phone:909-520-0392
Mailing Address - Fax:
Practice Address - Street 1:6781 ELM AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5740
Practice Address - Country:US
Practice Address - Phone:909-520-0392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-30
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50890225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant