Provider Demographics
NPI:1104308394
Name:NGUYEN, JOHNNY THANH
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:THANH
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 116TH AVE NE STE 605
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-4697
Mailing Address - Country:US
Mailing Address - Phone:425-454-8161
Mailing Address - Fax:425-454-9304
Practice Address - Street 1:1135 116TH AVE NE STE 605
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4697
Practice Address - Country:US
Practice Address - Phone:425-454-8161
Practice Address - Fax:425-454-9304
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program