Provider Demographics
NPI:1902420912
Name:NGUYEN, KEVIN DATHIEN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DATHIEN
Last Name:NGUYEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 E HOLT AVE
Mailing Address - Street 2:STE A
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-5823
Mailing Address - Country:US
Mailing Address - Phone:909-988-2555
Mailing Address - Fax:909-460-6600
Practice Address - Street 1:1501 E HOLT AVE # A
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5823
Practice Address - Country:US
Practice Address - Phone:909-623-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant