Healthcare Provider Details

I. General information

NPI: 1316631963
Provider Name (Legal Business Name): ANGELA PHAM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S EASTON RD
GLENSIDE PA
19038-3215
US

IV. Provider business mailing address

4305 W WHEATLAND RD STE 101
DALLAS TX
75237-3455
US

V. Phone/Fax

Practice location:
  • Phone: 215-572-2900
  • Fax:
Mailing address:
  • Phone: 972-708-9494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: