Healthcare Provider Details

I. General information

NPI: 1164202396
Provider Name (Legal Business Name): ANDREW NGUYEN DO A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 NEWPORT CENTER DR STE 110
NEWPORT BEACH CA
92660-7541
US

IV. Provider business mailing address

4680 POLARIS AVE STE 200
LAS VEGAS NV
89103-5600
US

V. Phone/Fax

Practice location:
  • Phone: 702-909-5903
  • Fax:
Mailing address:
  • Phone: 702-909-6400
  • Fax: 855-576-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREW NGUYEN
Title or Position: MANAGING PARTNER
Credential: DO
Phone: 702-909-5903