Provider Demographics
NPI:1427669357
Name:NGUYEN, CHOM PHOU (PA-C)
Entity type:Individual
Prefix:
First Name:CHOM
Middle Name:PHOU
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 1:535 JESSE JEWELL PKWY SE STE C
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3772
Mailing Address - Country:US
Mailing Address - Phone:770-534-9014
Mailing Address - Fax:770-534-9012
Practice Address - Street 1:535 JESSE JEWELL PKWY SE STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3772
Practice Address - Country:US
Practice Address - Phone:770-534-9014
Practice Address - Fax:770-534-9012
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant