Basic Information
| Provider Information | |||||||||
| NPI: | 1467454306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | KHANH | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 GRANDE DR | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325045935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504777042 | ||||||||
| FaxNumber: | 8504749060 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 GRANDE DR | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325045935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504777042 | ||||||||
| FaxNumber: | 8504749060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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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 | 207L00000X | ME69876 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 31822 | 01 | FL | BLUECROSS & BLUESHIELD | OTHER | 59136247 | 01 | AL | BLUECROSS & BLUESHIELD | OTHER | 592-15457 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER | Z182 | 01 | FL | HEALTH FIRST NETWORK | OTHER | 009953520 | 05 | AL | MEDICAID | 250043400 | 05 | FL | MEDICAID | 050051897 | 01 | FL | RAILROAD MEDICARE | OTHER | 131080 | 05 | AL | MEDICAID |