Healthcare Provider Details

I. General information

NPI: 1669399507
Provider Name (Legal Business Name): JOHN LE NGUYEN
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S EASTON RD
GLENSIDE PA
19038-3295
US

IV. Provider business mailing address

450 S EASTON RD
GLENSIDE PA
19038-3295
US

V. Phone/Fax

Practice location:
  • Phone: 215-517-2331
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: