Healthcare Provider Details

I. General information

NPI: 1417118860
Provider Name (Legal Business Name): MARY ELIZABETH HOANG PHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WALLACE BLVD
AMARILLO TX
79106-1799
US

IV. Provider business mailing address

PO BOX 2533
AMARILLO TX
79105-2533
US

V. Phone/Fax

Practice location:
  • Phone: 806-212-2129
  • Fax: 806-212-2246
Mailing address:
  • Phone: 806-212-6965
  • Fax: 806-212-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberP0924
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: