Healthcare Provider Details

I. General information

NPI: 1609111665
Provider Name (Legal Business Name): JACQUELINE KIM NGUYEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3273 CLAREMONT WAY STE 100
NAPA CA
94558
US

IV. Provider business mailing address

3273 CLAREMONT WAY STE 100
NAPA CA
94558-3328
US

V. Phone/Fax

Practice location:
  • Phone: 707-254-7117
  • Fax: 707-265-6435
Mailing address:
  • Phone: 310-702-2084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number56195
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberA128602
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: