Basic Information
| Provider Information | |||||||||
| NPI: | 1134363682 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | DUC | ||||||||
| MiddleName: | THANH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6653 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162044500 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 LANSING ST | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130211983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155670437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2009 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 23 013181 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 013181 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 03142665 | 05 | NY | MEDICAID |