Healthcare Provider Details

I. General information

NPI: 1619980547
Provider Name (Legal Business Name): NICHOLAS MINH PHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14239 W BELL RD SUITE 112
SURPRISE AZ
85374-2469
US

IV. Provider business mailing address

14239 W BELL RD SUITE 112
SURPRISE AZ
85374-2469
US

V. Phone/Fax

Practice location:
  • Phone: 623-876-9983
  • Fax: 623-876-9984
Mailing address:
  • Phone: 623-876-9983
  • Fax: 623-876-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number28681
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: