Healthcare Provider Details

I. General information

NPI: 1508635012
Provider Name (Legal Business Name): MIMI PHAM NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 CAREW ST STE 322
SPRINGFIELD MA
01104-2431
US

IV. Provider business mailing address

299 CAREW ST
SPRINGFIELD MA
01104-2301
US

V. Phone/Fax

Practice location:
  • Phone: 508-373-5607
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA102162
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA102162
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: