Provider Demographics
NPI:1487162715
Name:TYKES TO TEENS PEDIATRICS, PA
Entity type:Organization
Organization Name:TYKES TO TEENS PEDIATRICS, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANH
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-723-6446
Mailing Address - Street 1:5607 AVON LANDING LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-3550
Mailing Address - Country:US
Mailing Address - Phone:832-723-6446
Mailing Address - Fax:
Practice Address - Street 1:17510 W GRAND PKWY S STE 580
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2649
Practice Address - Country:US
Practice Address - Phone:281-341-9600
Practice Address - Fax:832-595-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8959261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030251503Medicaid