Basic Information
| Provider Information | |||||||||
| NPI: | 1972098606 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | NHAT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607263260 | ||||||||
| FaxNumber: | 6162520841 | ||||||||
| Practice Location | |||||||||
| Address1: | 11603 STATE AVE STE G | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982718465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606586800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2018 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OP61194203 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 5101024070 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.