Healthcare Provider Details

I. General information

NPI: 1134787427
Provider Name (Legal Business Name): MARIE THI NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date: 02/17/2026
Reactivation Date: 02/25/2026

III. Provider practice location address

111 E DUNLAP AVE STE 1-279
PHOENIX AZ
85020-2807
US

IV. Provider business mailing address

111 E DUNLAP AVE STE 1-279
PHOENIX AZ
85020-2807
US

V. Phone/Fax

Practice location:
  • Phone: 480-331-6721
  • Fax: --
Mailing address:
  • Phone: 480-331-6721
  • Fax: --

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: