Healthcare Provider Details

I. General information

NPI: 1710776240
Provider Name (Legal Business Name): KHAI QUANG NGO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2025
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 HOLLIS ST
MANCHESTER NH
03101-1235
US

IV. Provider business mailing address

145 HOLLIS ST
MANCHESTER NH
03101-1235
US

V. Phone/Fax

Practice location:
  • Phone: 603-626-9500
  • Fax: 833-448-1486
Mailing address:
  • Phone: 603-626-9500
  • Fax: 833-448-1486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3621
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: