Healthcare Provider Details

I. General information

NPI: 1851713358
Provider Name (Legal Business Name): PHONG TRUONG LE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2014
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14655 GALAXIE AVE
APPLE VALLEY MN
55124-8602
US

IV. Provider business mailing address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

V. Phone/Fax

Practice location:
  • Phone: 952-432-6161
  • Fax:
Mailing address:
  • Phone: 763-520-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11521
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: