Healthcare Provider Details

I. General information

NPI: 1437172947
Provider Name (Legal Business Name): QUYNH-NHU PHAM NIZZA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: QUYNH-NHU THI PHAM M.D.

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 12/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 N BROADWAY PBO CREDENTIALING
EVERETT WA
98201-1409
US

IV. Provider business mailing address

12800 BOTHELL-EVERETT HWY
EVERETT WA
98208-6644
US

V. Phone/Fax

Practice location:
  • Phone: 425-317-0699
  • Fax: 425-317-0291
Mailing address:
  • Phone: 425-316-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00045858
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58998
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD427869
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD00045858
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: