Healthcare Provider Details

I. General information

NPI: 1073045449
Provider Name (Legal Business Name): TRA V PHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1081 N CHINA LAKE BLVD
RIDGECREST CA
93555-3130
US

IV. Provider business mailing address

1081 N CHINA LAKE BLVD
RIDGECREST CA
93555-3130
US

V. Phone/Fax

Practice location:
  • Phone: 760-446-3551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA196360
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number87896
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: