Provider Demographics
NPI:1477200806
Name:NGUYEN, PHUONG QUYNH THI (PA-C)
Entity type:Individual
Prefix:
First Name:PHUONG QUYNH
Middle Name:THI
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 1:1003 OLDE WATERFORD WAY STE 1C
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4168
Mailing Address - Country:US
Mailing Address - Phone:910-769-5004
Mailing Address - Fax:
Practice Address - Street 1:1003 OLDE WATERFORD WAY STE 1C
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4168
Practice Address - Country:US
Practice Address - Phone:910-769-5004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-06
Last Update Date:2022-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12529363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant