Healthcare Provider Details

I. General information

NPI: 1689328833
Provider Name (Legal Business Name): MIMI CAO-PHAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 HANOVER PKWY STE 204&205
GREENBELT MD
20770-2010
US

IV. Provider business mailing address

13011 INNISBROOK DR
BELTSVILLE MD
20705-1195
US

V. Phone/Fax

Practice location:
  • Phone: 301-232-3638
  • Fax:
Mailing address:
  • Phone: 301-466-5072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC0008351
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0008351
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: