Provider Demographics
NPI:1336611631
Name:NGUYEN, VINA (PA-C)
Entity Type:Individual
Prefix:
First Name:VINA
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 888584
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-8584
Mailing Address - Country:US
Mailing Address - Phone:925-691-9806
Mailing Address - Fax:925-691-9807
Practice Address - Street 1:4530 BALFOUR RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-1581
Practice Address - Country:US
Practice Address - Phone:925-691-9806
Practice Address - Fax:925-691-9807
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59625363A00000X
TN3760363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA59625OtherSTATE LICENSE
CA59625OtherSTATE LICENSE