Healthcare Provider Details

I. General information

NPI: 1649892357
Provider Name (Legal Business Name): TRINH MONG HOANG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 N WEBB RD
WICHITA KS
67206-3405
US

IV. Provider business mailing address

1921 N WEBB RD
WICHITA KS
67206-3405
US

V. Phone/Fax

Practice location:
  • Phone: 316-612-4815
  • Fax:
Mailing address:
  • Phone: 316-612-4815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15-02414
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14619
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: