Provider Demographics
NPI:1598347189
Name:NGUYEN, LISA MY PHUNG (DO)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MY PHUNG
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 ROY SMITH ST APT 1503
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1359
Mailing Address - Country:US
Mailing Address - Phone:954-235-4635
Mailing Address - Fax:
Practice Address - Street 1:2200 ROY RICHARD DR
Practice Address - Street 2:
Practice Address - City:SCHERTZ
Practice Address - State:TX
Practice Address - Zip Code:78154-2723
Practice Address - Country:US
Practice Address - Phone:210-566-4777
Practice Address - Fax:210-566-4779
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO4856390200000X
TXV0077208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program