Healthcare Provider Details

I. General information

NPI: 1043940513
Provider Name (Legal Business Name): HUNG PHAM PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 AIRPORT FWY
BEDFORD TX
76021-6117
US

IV. Provider business mailing address

4956 PADDOCK DR
FORT WORTH TX
76244-6139
US

V. Phone/Fax

Practice location:
  • Phone: 817-354-5200
  • Fax:
Mailing address:
  • Phone: 682-227-9272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1078765
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1078765
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: