Healthcare Provider Details

I. General information

NPI: 1720804651
Provider Name (Legal Business Name): TRUNG VU PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOEY VU PA

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E STATE ST
ITHACA NY
14850-5547
US

IV. Provider business mailing address

1458 CHILI AVE
ROCHESTER NY
14624-3263
US

V. Phone/Fax

Practice location:
  • Phone: 607-274-3011
  • Fax:
Mailing address:
  • Phone: 585-351-4733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number033779
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: