Healthcare Provider Details

I. General information

NPI: 1730550013
Provider Name (Legal Business Name): DIEU LINH THI NGUYEN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 S MAIN ST
KELLER TX
76248-4936
US

IV. Provider business mailing address

PO BOX 9101
COPPELL TX
75019-9494
US

V. Phone/Fax

Practice location:
  • Phone: 817-431-2800
  • Fax: 718-431-0371
Mailing address:
  • Phone: 972-745-7500
  • Fax: 972-471-0700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10247
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: