Healthcare Provider Details

I. General information

NPI: 1952756298
Provider Name (Legal Business Name): MAI NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2016
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST FL 2
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

550 PEACHTREE ST NE MEDICAL OFFICE TOWER/STE 1135
ATLANTA GA
30308-2212
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-3000
  • Fax:
Mailing address:
  • Phone: 404-686-1424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberT1489
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: