Healthcare Provider Details

I. General information

NPI: 1992538920
Provider Name (Legal Business Name): BAOTRAM THAI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E DUNLAP AVE
PHOENIX AZ
85020-2825
US

IV. Provider business mailing address

5461 N 87TH DR
GLENDALE AZ
85305-2299
US

V. Phone/Fax

Practice location:
  • Phone: 238-160-2943
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number270826
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: