Provider Demographics
NPI:1922827278
Name:NGUYEN, PHUONG UYEN BAO (PA-C)
Entity type:Individual
Prefix:
First Name:PHUONG UYEN
Middle Name:BAO
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 1:625 BEAVER RUIN RD NW STE E
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3407
Mailing Address - Country:US
Mailing Address - Phone:678-369-9399
Mailing Address - Fax:
Practice Address - Street 1:625 BEAVER RUIN RD NW STE E
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3407
Practice Address - Country:US
Practice Address - Phone:678-369-9399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12589363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical