=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538040001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICOLE PHAM DPM PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2025
-----------------------------------------------------
Last Update Date | 11/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1140 NORMAN DR STE 1
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95336-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-823-2700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1140 NORMAN DR STE 1
-----------------------------------------------------
City | MANTECA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95336-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NICOLE PHAM
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 925-980-5577
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------