Provider Demographics
NPI:1396534624
Name:NGUYEN, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N CAPITOL AVE APT 109
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95133-2721
Mailing Address - Country:US
Mailing Address - Phone:510-605-6796
Mailing Address - Fax:
Practice Address - Street 1:4010 MOORPARK AVE STE 112
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1803
Practice Address - Country:US
Practice Address - Phone:408-441-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52162225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant