Healthcare Provider Details

I. General information

NPI: 1700448917
Provider Name (Legal Business Name): NGOC NGUYEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 11/07/2024
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MCAULEY DR SUITE 6109
YPSILANTI MI
48197
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 734-712-1400
  • Fax: 734-623-2857
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010276
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004649
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: