Provider Demographics
NPI:1831907740
Name:NGUYEN, PHUONG HOAI
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:HOAI
Last Name:NGUYEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 OLD LEE HWY STE 210A
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4367
Mailing Address - Country:US
Mailing Address - Phone:703-642-6633
Mailing Address - Fax:
Practice Address - Street 1:2812 OLD LEE HWY STE 210A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4367
Practice Address - Country:US
Practice Address - Phone:703-642-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-23
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110010452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant