Provider Demographics
NPI:1316257314
Name:NGUYEN, STEPHANIE CHAN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CHAN
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SW JOHNSON AVE
Mailing Address - Street 2:STE C
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5834
Mailing Address - Country:US
Mailing Address - Phone:817-766-7421
Mailing Address - Fax:817-447-8100
Practice Address - Street 1:621 SW JOHNSON AVE
Practice Address - Street 2:STE C
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-5834
Practice Address - Country:US
Practice Address - Phone:817-766-7421
Practice Address - Fax:817-447-8100
Is Sole Proprietor?:No
Enumeration Date:2010-10-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA06983363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program