Basic Information
| Provider Information | |||||||||
| NPI: | 1639721053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NGUYEN | ||||||||
| FirstName: | NAM | ||||||||
| MiddleName: | SON | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12900 PARK PLAZA DR # 3150 | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907039329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626222800 | ||||||||
| FaxNumber: | 5627414479 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 N WHITE RD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951271964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085037600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2019 | ||||||||
| LastUpdateDate: | 09/04/2019 | ||||||||
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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 | 363LF0000X | 95010560 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.