Healthcare Provider Details

I. General information

NPI: 1821587346
Provider Name (Legal Business Name): ETHAN D NGUYEN NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13065 W MCDOWELL RD STE A105
AVONDALE AZ
85392-6440
US

IV. Provider business mailing address

13065 W MCDOWELL RD STE A105
AVONDALE AZ
85392-6440
US

V. Phone/Fax

Practice location:
  • Phone: 623-536-6788
  • Fax: 235-369-2886
Mailing address:
  • Phone: 623-536-6788
  • Fax: 623-536-9288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF09190130
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: