Provider Demographics
NPI:1295207447
Name:PHAM, THANG BAO (PA)
Entity Type:Individual
Prefix:
First Name:THANG
Middle Name:BAO
Last Name:PHAM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 VERDUGO BLVD STE 414
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1474
Mailing Address - Country:US
Mailing Address - Phone:818-265-5400
Mailing Address - Fax:
Practice Address - Street 1:544 N GLENDALE AVE STE A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-3311
Practice Address - Country:US
Practice Address - Phone:818-241-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant