Healthcare Provider Details

I. General information

NPI: 1194721407
Provider Name (Legal Business Name): NGUYEN H PHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 11/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 N LAKE DR STE 206
MILWAUKEE WI
53211-4528
US

IV. Provider business mailing address

2350 N LAKE DR STE 206
MILWAUKEE WI
53211-4528
US

V. Phone/Fax

Practice location:
  • Phone: 414-298-7280
  • Fax: 414-298-7281
Mailing address:
  • Phone: 414-298-7280
  • Fax: 414-298-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number45546 020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: