Provider Demographics
NPI:1063979136
Name:NGUYEN, JOE (SCALP MICROPIGMENTAT)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:SCALP MICROPIGMENTAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 AURORA DR STE 102B
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3105
Mailing Address - Country:US
Mailing Address - Phone:510-258-9543
Mailing Address - Fax:
Practice Address - Street 1:1515 AURORA DR STE 102B
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-3105
Practice Address - Country:US
Practice Address - Phone:510-258-9543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management