Healthcare Provider Details

I. General information

NPI: 1245705086
Provider Name (Legal Business Name): RYAN DUY PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 SAN JOAQUIN HILLS RD
NEWPORT BEACH CA
92660-6505
US

IV. Provider business mailing address

11744 SUMMERWOOD CT
FOUNTAIN VALLEY CA
92708-2668
US

V. Phone/Fax

Practice location:
  • Phone: 949-760-9222
  • Fax: 949-579-2906
Mailing address:
  • Phone: 714-401-8579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56054
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: