Provider Demographics
NPI:1700030954
Name:NGUYEN, KIM ANH (DO)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:ANH
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 S RAINBOW BLVD STE 5
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-4209
Mailing Address - Country:US
Mailing Address - Phone:702-763-2002
Mailing Address - Fax:877-414-2638
Practice Address - Street 1:5920 S RAINBOW BLVD STE 5
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-4209
Practice Address - Country:US
Practice Address - Phone:702-763-2002
Practice Address - Fax:877-414-2638
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVDO2258208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1871164855Medicaid
NV14700030954Medicaid
NVDO2258OtherMEDICAL LICENSE