Healthcare Provider Details

I. General information

NPI: 1366256166
Provider Name (Legal Business Name): HUAN TRI PHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9024 BOLSA AVE
WESTMINSTER CA
92683-5531
US

IV. Provider business mailing address

9024 BOLSA AVE
WESTMINSTER CA
92683-5531
US

V. Phone/Fax

Practice location:
  • Phone: 626-573-9003
  • Fax:
Mailing address:
  • Phone: 714-899-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA65843
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: