Healthcare Provider Details

I. General information

NPI: 1831501345
Provider Name (Legal Business Name): THANH TRUNG T NGUYEN PA-C, MSPAS, MPH, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2052 MCGEE AVE
BERKELEY CA
94703-1417
US

IV. Provider business mailing address

2344 6TH ST
BERKELEY CA
94710-2412
US

V. Phone/Fax

Practice location:
  • Phone: 510-387-8369
  • Fax:
Mailing address:
  • Phone: 510-981-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number51629
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: