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General NPI Number Information
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NPI Number | 1912513987
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Entity Type | Individual
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Provider Name | JACQUELYN DAN-PHUNG NGUYEN PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/16/2020
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Last Update Date | 03/06/2023
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Provider Practice Location Address
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Address Line | 2103 LANTERN LN
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City | ORELAND
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State | PA
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Zip | 19075-2513
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Country | US
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Telephone | 901-641-3000
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Fax | 901-373-0804
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Provider Business Mailing Address
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Address Line | 2103 LANTERN LN
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City | ORELAND
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State | PA
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Zip | 19075-2513
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Country | US
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Telephone | 267-626-1377
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Fax | 267-626-1377
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 4276
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 4276
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License Number State | TN
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