Basic Information
| Provider Information | |||||||||
| NPI: | 1417118860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | MARY ELIZABETH | ||||||||
| MiddleName: | HOANG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2533 | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791052533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062126965 | ||||||||
| FaxNumber: | 8062126278 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 WALLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | AMARILLO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 791061799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8062122129 | ||||||||
| FaxNumber: | 8062122246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | P0924 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 310900102 | 05 | TX | MEDICAID |