Provider Demographics
NPI:1770166357
Name:NGUYEN, TRISTY TRA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:TRISTY
Middle Name:TRA
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5434 BURWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-4706
Mailing Address - Country:US
Mailing Address - Phone:856-857-7198
Mailing Address - Fax:
Practice Address - Street 1:5434 BURWOOD AVE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-4706
Practice Address - Country:US
Practice Address - Phone:856-857-7198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00617900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant