Healthcare Provider Details

I. General information

NPI: 1649995937
Provider Name (Legal Business Name): MR. HUAN PHU PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: HUAN PHU PHAM FRESCO

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 10/10/2022
Certification Date: 10/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5252 EL CAJON BLVD APT 208
SAN DIEGO CA
92115-4762
US

IV. Provider business mailing address

5252 EL CAJON BLVD APT 208
SAN DIEGO CA
92115-4762
US

V. Phone/Fax

Practice location:
  • Phone: 619-314-2728
  • Fax:
Mailing address:
  • Phone: 619-314-2728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102X00000X
TaxonomyPoetry Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code331L00000X
TaxonomyBlood Bank
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code344800000X
TaxonomyAir Carrier
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code347D00000X
TaxonomyTrain
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code1744R1103X
TaxonomyResearch Study Abstracter/Coder
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: