Provider Demographics
NPI:1881900405
Name:NGUYEN, MAI (PTA)
Entity type:Individual
Prefix:
First Name:MAI
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8712 BLUE MAIDEN WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-3807
Mailing Address - Country:US
Mailing Address - Phone:209-568-8886
Mailing Address - Fax:
Practice Address - Street 1:8712 BLUE MAIDEN WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-3807
Practice Address - Country:US
Practice Address - Phone:209-568-8886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6862225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant