Healthcare Provider Details

I. General information

NPI: 1275947103
Provider Name (Legal Business Name): PHUONG DUONG THOAI NGUYEN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 W FAIRVIEW ST STE B
COLFAX WA
99111-5106
US

IV. Provider business mailing address

2755 SILVER CREEK RD STE 111&113
BULLHEAD CITY AZ
86442-7904
US

V. Phone/Fax

Practice location:
  • Phone: 509-397-2675
  • Fax:
Mailing address:
  • Phone: 928-704-7163
  • Fax: 928-704-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number007988
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOP61447850
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: