Healthcare Provider Details

I. General information

NPI: 1629752530
Provider Name (Legal Business Name): LYAN NGUYEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 DALTON AVE
PITTSFIELD MA
01201-2903
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 413-242-6577
  • Fax:
Mailing address:
  • Phone: 603-319-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA102048
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: