Provider Demographics
NPI:1659103653
Name:PHUNG, TUAN (PA-C)
Entity type:Individual
Prefix:
First Name:TUAN
Middle Name:
Last Name:PHUNG
Suffix:
Gender:M
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 1:6205 RED CEDAR CIR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-8868
Mailing Address - Country:US
Mailing Address - Phone:479-719-0667
Mailing Address - Fax:
Practice Address - Street 1:5228 W PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5005
Practice Address - Country:US
Practice Address - Phone:972-250-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-17
Last Update Date:2024-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty