Provider Demographics
NPI:1417784471
Name:NGUYEN, PHUONG THAO THI
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:THAO THI
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 1:3974 LEEWARD CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5288
Mailing Address - Country:US
Mailing Address - Phone:404-403-5822
Mailing Address - Fax:
Practice Address - Street 1:1700 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2195
Practice Address - Country:US
Practice Address - Phone:770-979-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant