Provider Demographics
NPI:1043973530
Name:NGUYEN, AMANDA MY-VY (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MY-VY
Last Name:NGUYEN
Suffix:
Gender:F
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 1:3310 CARDIFF AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45209-1382
Mailing Address - Country:US
Mailing Address - Phone:513-550-9921
Mailing Address - Fax:
Practice Address - Street 1:270 SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-3023
Practice Address - Country:US
Practice Address - Phone:513-367-5888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007183RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH102234704-00Medicaid