Provider Demographics
NPI:1134678063
Name:PHAM, ELIZA (MA, ATC)
Entity Type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 SPORTS CAMP DR
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:PA
Mailing Address - Zip Code:16882-8422
Mailing Address - Country:US
Mailing Address - Phone:814-349-5633
Mailing Address - Fax:
Practice Address - Street 1:134 SPORTS CAMP DR
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:PA
Practice Address - Zip Code:16882-8422
Practice Address - Country:US
Practice Address - Phone:814-349-5633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0051592081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine