Healthcare Provider Details

I. General information

NPI: 1013397066
Provider Name (Legal Business Name): PREMIER PROVIDER HEALTH PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 JAMES CASEY ST STE B-100
AUSTIN TX
78745-1142
US

IV. Provider business mailing address

7314 CENTENARY AVE STE 700
DALLAS TX
75225-4624
US

V. Phone/Fax

Practice location:
  • Phone: 512-444-4325
  • Fax:
Mailing address:
  • Phone: 214-274-1507
  • Fax: 512-354-1106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberM0223
License Number StateTX

VIII. Authorized Official

Name: DR. HAN NGOC PHAM
Title or Position: CEO
Credential: M.D.
Phone: 214-274-1507