MEDICARE: JIM PHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer		TX

General Provider Information

NPI Number	:	1811681174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIM PHAM

Provider Business Mailing Address
First Line	:	515 JUNIPER DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-1460
Country	:	US
Telephone Number	:	682-203-8005
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 JUNIPER DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76018-1460
Country	:	US
Telephone Number	:	682-203-8005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2023
Last Update Date	:	06/26/2023

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Directions to “ JIM PHAM ” Practice Location

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