Healthcare Provider Details

I. General information

NPI: 1235520693
Provider Name (Legal Business Name): TONY NGUYEN CAO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720A MEDICAL PARK DR STE 220
BILOXI MS
39532
US

IV. Provider business mailing address

6300 E LAKE BLVD STE 301
VANCLEAVE MS
39565-6771
US

V. Phone/Fax

Practice location:
  • Phone: 228-230-2663
  • Fax: 228-546-3257
Mailing address:
  • Phone: 228-230-2663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200790
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00293
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: