Healthcare Provider Details

I. General information

NPI: 1699546903
Provider Name (Legal Business Name): TAN HUNG NGO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD MEDICAL CENTER PLAZA SUITE 200
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-8840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14152
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: