Healthcare Provider Details

I. General information

NPI: 1184268666
Provider Name (Legal Business Name): TONY HOANG NGUYEN LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 UNIVERSITY DR
RADFORD VA
24141
US

IV. Provider business mailing address

PO BOX 6913
RADFORD VA
24142-6913
US

V. Phone/Fax

Practice location:
  • Phone: 540-831-7831
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0126003278
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: