=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538331665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHANH NGOC PHAM M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2008
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1135 116TH AVE NE STE 620
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-454-8016
-----------------------------------------------------
Fax | 425-453-2827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1135 116TH AVE NE STE 620
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-4636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-454-8016
-----------------------------------------------------
Fax | 425-453-2827
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | MD60337799
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------