Provider Demographics
NPI:1114245339
Name:PHAM, NATHAN (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 BRIAR FRST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-1415
Mailing Address - Country:US
Mailing Address - Phone:305-496-4409
Mailing Address - Fax:
Practice Address - Street 1:4511 BRIAR FRST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-1415
Practice Address - Country:US
Practice Address - Phone:305-496-4409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2020-09-04
Deactivation Date:2014-03-12
Deactivation Code:
Reactivation Date:2020-09-04
Provider Licenses
StateLicense IDTaxonomies
TXBP10037842207Q00000X
FLPS58864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine