=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255601258
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTHONY QUANG PHAM D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2012
-----------------------------------------------------
Last Update Date | 09/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7817 SE STARK ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97215-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-975-5298
-----------------------------------------------------
Fax | 503-546-7496
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7817 SE STARK ST
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97215-2339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-975-5298
-----------------------------------------------------
Fax | 503-546-7496
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 5021
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038012525
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------