Provider Demographics
NPI:1881363976
Name:NGUYEN, KHOA (APRN, CNP)
Entity type:Individual
Prefix:
First Name:KHOA
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 W KENYON RD STE B
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1010
Mailing Address - Country:US
Mailing Address - Phone:217-819-3376
Mailing Address - Fax:217-729-7788
Practice Address - Street 1:1111 W KENYON RD STE B
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-1010
Practice Address - Country:US
Practice Address - Phone:217-819-3376
Practice Address - Fax:217-729-7788
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023980363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner