Healthcare Provider Details

I. General information

NPI: 1841261088
Provider Name (Legal Business Name): KHANH XONG NGUYEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7455 VILLAGE DR
LINO LAKES MN
55014-1181
US

IV. Provider business mailing address

7455 VILLAGE DR
LINO LAKES MN
55014-1181
US

V. Phone/Fax

Practice location:
  • Phone: 651-717-3400
  • Fax:
Mailing address:
  • Phone: 651-717-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOL60020645
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03645
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO155697
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number20A9302
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number64306
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: