Provider Demographics
NPI:1841261088
Name:NGUYEN, KHANH XONG (DO)
Entity type:Individual
Prefix:DR
First Name:KHANH
Middle Name:XONG
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7455 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55014-1181
Mailing Address - Country:US
Mailing Address - Phone:651-717-3400
Mailing Address - Fax:
Practice Address - Street 1:7455 VILLAGE DR
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55014-1181
Practice Address - Country:US
Practice Address - Phone:651-717-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL60020645207Q00000X
KY03645207Q00000X
ORDO155697207Q00000X
CA20A9302208D00000X
MN64306207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22959Medicaid
IN201215060Medicaid
KY7100270190Medicaid
ORR0000WCJHTMedicare Oscar/Certification
KYK115820Medicare PIN