Healthcare Provider Details

I. General information

NPI: 1164257663
Provider Name (Legal Business Name): DIANA KIM NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 PENNSYLVANIA AVE STE 690
FORT WORTH TX
76104-2133
US

IV. Provider business mailing address

349 CORRAL ACRES WAY
FORT WORTH TX
76120-4306
US

V. Phone/Fax

Practice location:
  • Phone: 817-761-7740
  • Fax: 817-761-7742
Mailing address:
  • Phone: 817-718-8373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA18707
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: