Provider Demographics
NPI:1114371887
Name:PHAM, KIM OANH (PTA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:OANH
Last Name:PHAM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16103 STAGS LEAP DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-2003
Mailing Address - Country:US
Mailing Address - Phone:813-325-9562
Mailing Address - Fax:
Practice Address - Street 1:3248 LITHIA PINECREST RD STE 102
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5682
Practice Address - Country:US
Practice Address - Phone:813-622-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 26602225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant