Healthcare Provider Details

I. General information

NPI: 1770166019
Provider Name (Legal Business Name): KHOA DANG NGUYEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2021
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 ONONDAGA AVE
SAN FRANCISCO CA
94112-3212
US

IV. Provider business mailing address

1282 MARKET ST
SAN FRANCISCO CA
94102-4801
US

V. Phone/Fax

Practice location:
  • Phone: 510-899-3717
  • Fax:
Mailing address:
  • Phone: 510-899-3717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-QCRZBG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: