Healthcare Provider Details

I. General information

NPI: 1083289649
Provider Name (Legal Business Name): NICOLE PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 NORMAN DR STE 1
MANTECA CA
95336-5900
US

IV. Provider business mailing address

1140 NORMAN DR STE 1
MANTECA CA
95336-5900
US

V. Phone/Fax

Practice location:
  • Phone: 209-823-2700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE6082
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: