Healthcare Provider Details

I. General information

NPI: 1811568835
Provider Name (Legal Business Name): DANI HOANG NGUYEN PA-C, CAQ-PSYCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S WESTERN AVE UNIT 1
CHICAGO IL
60612-4644
US

IV. Provider business mailing address

119 S WESTERN AVE UNIT 1 #165
CHICAGO IL
60612-4644
US

V. Phone/Fax

Practice location:
  • Phone: 312-625-0110
  • Fax:
Mailing address:
  • Phone: 312-625-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.008656
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.008656
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: