Provider Demographics
NPI:1003342981
Name:PHAM, VI T (PA-C)
Entity Type:Individual
Prefix:
First Name:VI
Middle Name:T
Last Name:PHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1080 CHINOOK LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1850
Mailing Address - Country:US
Mailing Address - Phone:719-564-9400
Mailing Address - Fax:719-564-0497
Practice Address - Street 1:1080 CHINOOK LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1850
Practice Address - Country:US
Practice Address - Phone:719-564-9400
Practice Address - Fax:719-564-0497
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004927363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0004927OtherDORA MEDICAL BOARD.