Healthcare Provider Details

I. General information

NPI: 1831379650
Provider Name (Legal Business Name): KRYSTAL H PHAM MD, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 W CHARLESTON BLVD
LAS VEGAS NV
89102-1944
US

IV. Provider business mailing address

3040 W CHARLESTON BLVD
LAS VEGAS NV
89102-1944
US

V. Phone/Fax

Practice location:
  • Phone: 702-477-0101
  • Fax: 702-477-0254
Mailing address:
  • Phone: 702-477-0101
  • Fax: 702-477-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number12284
License Number StateNV

VIII. Authorized Official

Name: KRYSTAL HANHTRAN PHAM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 702-477-0101