Provider Demographics
NPI:1639500820
Name:NGUYENPHAM, VINCENT (PTA)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:NGUYENPHAM
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 1:3801 S HOLLY PARK DR
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-3758
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4700 42ND AVE SW STE 510
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4583
Practice Address - Country:US
Practice Address - Phone:206-933-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160339911225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant