Healthcare Provider Details

I. General information

NPI: 1063014298
Provider Name (Legal Business Name): BAO XUAN HOANG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 S STATE ROAD 7
WELLINGTON FL
33414-6135
US

IV. Provider business mailing address

1049 S STATE ROAD 7
WELLINGTON FL
33414-6135
US

V. Phone/Fax

Practice location:
  • Phone: 561-250-7047
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9113574
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: