Healthcare Provider Details

I. General information

NPI: 1144954488
Provider Name (Legal Business Name): ETHAN PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 E GUADALUPE RD
TEMPE AZ
85283-3044
US

IV. Provider business mailing address

2722 N 7TH ST UNIT 8
PHOENIX AZ
85006-1067
US

V. Phone/Fax

Practice location:
  • Phone: 480-491-1898
  • Fax:
Mailing address:
  • Phone: 714-908-6037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: