Healthcare Provider Details

I. General information

NPI: 1164417010
Provider Name (Legal Business Name): KHANH Q NGUYEN PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

PO BOX 4059
WAYNE NJ
07474-4059
US

V. Phone/Fax

Practice location:
  • Phone: 407-609-0095
  • Fax: 407-609-0096
Mailing address:
  • Phone: 973-826-8291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9102312
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102312
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: