Healthcare Provider Details

I. General information

NPI: 1265115406
Provider Name (Legal Business Name): KIM NGAN PHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIM PHAM PA-C

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13522 NEWPORT AVE STE 102
TUSTIN CA
92780-3707
US

IV. Provider business mailing address

13522 NEWPORT AVE STE 102
TUSTIN CA
92780-3707
US

V. Phone/Fax

Practice location:
  • Phone: 714-987-1121
  • Fax: 551-236-2481
Mailing address:
  • Phone: 714-987-1121
  • Fax: 551-236-2481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMP0684921
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1265115406
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number67708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: