Healthcare Provider Details

I. General information

NPI: 1194318436
Provider Name (Legal Business Name): THONG PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 03/12/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9855 ERMA RD STE 133
SAN DIEGO CA
92131-1092
US

IV. Provider business mailing address

9855 ERMA RD STE 133
SAN DIEGO CA
92131-1092
US

V. Phone/Fax

Practice location:
  • Phone: 858-343-4572
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95030195
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95244483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: