Provider Demographics
NPI:1104193226
Name:PHAM, THAO
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22121 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-2015
Mailing Address - Country:US
Mailing Address - Phone:718-468-6923
Mailing Address - Fax:718-468-6925
Practice Address - Street 1:22121 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-2015
Practice Address - Country:US
Practice Address - Phone:718-468-6923
Practice Address - Fax:718-468-6925
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY643221163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse