Basic Information
| Provider Information | |||||||||
| NPI: | 1346853074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANG | ||||||||
| FirstName: | PHONG | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5520 HIDDEN TRAIL LN | ||||||||
| Address2: | |||||||||
| City: | WARR ACRES | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731325825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054735045 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9800 BROADWAY EXT STE 200 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731146304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057154496 | ||||||||
| FaxNumber: | 4057154499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2020 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3207 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.