Healthcare Provider Details

I. General information

NPI: 1639673221
Provider Name (Legal Business Name): LINDA KIM PHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 MCCARTY LN
LAFAYETTE IN
47905-8764
US

IV. Provider business mailing address

2212 S 12TH ST
TACOMA WA
98405-3026
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-838-4758
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number01094355A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01094355A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number01094355A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: