Healthcare Provider Details

I. General information

NPI: 1740641620
Provider Name (Legal Business Name): AMANDA LYNN PHAM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2677 N MAIN ST STE 130
SANTA ANA CA
92705-6665
US

IV. Provider business mailing address

2913 EL CAMINO REAL # 730
TUSTIN CA
92782-8909
US

V. Phone/Fax

Practice location:
  • Phone: 714-274-7577
  • Fax:
Mailing address:
  • Phone: 714-510-2474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A17059
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number20A17059
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: