Healthcare Provider Details

I. General information

NPI: 1487849188
Provider Name (Legal Business Name): DAVID T D PHAM APRN-FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 US HIGHWAY 80 E STE 458A
MESQUITE TX
75150-8109
US

IV. Provider business mailing address

4700 WATERS AVE MEMORIAL HEALTH UNIVERSITY MEDICAL CENTER IM EDU
SAVANNAH GA
31404
US

V. Phone/Fax

Practice location:
  • Phone: 972-289-2273
  • Fax: 972-439-1776
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1011822
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number922214
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTL2791
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: