Provider Demographics
NPI:1962149468
Name:NGUYEN, MICHELLE MINH-TAM
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MINH-TAM
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 1:10586 MOUNTAIN VIEW AVE
Mailing Address - Street 2:APT H
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5204
Mailing Address - Country:US
Mailing Address - Phone:408-355-8200
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1716
Practice Address - Country:US
Practice Address - Phone:408-355-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTL4093208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics