Healthcare Provider Details

I. General information

NPI: 1982156337
Provider Name (Legal Business Name): THANH-THAO NGUYEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD 3 SOUTHBRIDGE
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

10010 KENNERLY RD 3 SOUTHBRIDGE
SAINT LOUIS MO
63128-2106
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1328
  • Fax: 314-525-1378
Mailing address:
  • Phone: 314-525-1328
  • Fax: 314-525-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2016037335
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: