Healthcare Provider Details

I. General information

NPI: 1801565528
Provider Name (Legal Business Name): ANDREA AN PHAM OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N CORONADO DR STE A
SIERRA VISTA AZ
85635-6359
US

IV. Provider business mailing address

143 PALA AVE
SAN JOSE CA
95127-2344
US

V. Phone/Fax

Practice location:
  • Phone: 520-459-1529
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1112
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: