Basic Information
| Provider Information | |||||||||
| NPI: | 1710903257 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | NGUYEN | ||||||||
| FirstName: | KY | ||||||||
| MiddleName: | Q | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6210 E HIGHWAY 290 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787231142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124839596 | ||||||||
| FaxNumber: | 5124066216 | ||||||||
| Practice Location | |||||||||
| Address1: | 10401 ANDERSON MILL RD STE 110B | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787502579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122505571 | ||||||||
| FaxNumber: | 5124067300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 10915R | LA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | M8212 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 196285401 | 05 | TX | MEDICAID | 199517 | 05 | LA | MEDICAID | 196285403 | 05 | TX | MEDICAID | 196285402 | 05 | TX | MEDICAID | 196285404 | 05 | TX | MEDICAID |