Provider Demographics
NPI:1912513987
Name:NGUYEN, JACQUELYN DAN-PHUNG (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:DAN-PHUNG
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:ORELAND
Mailing Address - State:PA
Mailing Address - Zip Code:19075-2513
Mailing Address - Country:US
Mailing Address - Phone:267-626-1377
Mailing Address - Fax:267-626-1377
Practice Address - Street 1:2103 LANTERN LN
Practice Address - Street 2:
Practice Address - City:ORELAND
Practice Address - State:PA
Practice Address - Zip Code:19075-2513
Practice Address - Country:US
Practice Address - Phone:901-641-3000
Practice Address - Fax:901-373-0804
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4276363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1157550OtherNCCPA
TN4276OtherPHYSICIAN ASSISTANT