Healthcare Provider Details

I. General information

NPI: 1124675392
Provider Name (Legal Business Name): HUY PHAM PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5123 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-2672
US

IV. Provider business mailing address

1801 SMARTY JONES ST SE
ALBUQUERQUE NM
87123-2398
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-3333
  • Fax:
Mailing address:
  • Phone: 505-615-3157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1612
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: