Healthcare Provider Details

I. General information

NPI: 1124739131
Provider Name (Legal Business Name): MAXIMILIAN NATHANIEL VUONG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W THOMAS RD # 401
PHOENIX AZ
85013-4407
US

IV. Provider business mailing address

240 W THOMAS RD # 301
PHOENIX AZ
85013-4407
US

V. Phone/Fax

Practice location:
  • Phone: 602-406-6262
  • Fax: 602-406-6261
Mailing address:
  • Phone: 602-406-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9853
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: