Basic Information
Provider Information
NPI: 1003013756
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PHUNG
FirstName: ANDY
MiddleName:  
NamePrefix: MR.
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2651 MORGANTON BLVD SW
Address2:  
City: LENOIR
State: NC
PostalCode: 286458183
CountryCode: US
TelephoneNumber: 8287578950
FaxNumber: 8287578968
Practice Location
Address1: 2651 MORGANTON BLVD SW
Address2:  
City: LENOIR
State: NC
PostalCode: 286458183
CountryCode: US
TelephoneNumber: 8287578950
FaxNumber: 8287578968
Other Information
ProviderEnumerationDate: 06/27/2007
LastUpdateDate: 08/05/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X2010-00375NCY Allopathic & Osteopathic PhysiciansFamily Medicine 
207V00000X5101017157MIN Allopathic & Osteopathic PhysiciansObstetrics & Gynecology 

No ID Information.


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