Healthcare Provider Details

I. General information

NPI: 1679244164
Provider Name (Legal Business Name): RYAN PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date: 12/23/2024
Reactivation Date: 02/25/2025

III. Provider practice location address

1205 E NORTH ST
MANTECA CA
95336-4900
US

IV. Provider business mailing address

1205 E NORTH ST
MANTECA CA
95336-4900
US

V. Phone/Fax

Practice location:
  • Phone: 916-667-1172
  • Fax:
Mailing address:
  • Phone: 916-667-1172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA69136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: