Provider Demographics
NPI:1689328833
Name:CAO-PHAM, MIMI (PA-C)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:CAO-PHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13011 INNISBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1195
Mailing Address - Country:US
Mailing Address - Phone:301-466-5072
Mailing Address - Fax:
Practice Address - Street 1:7500 HANOVER PKWY STE 204&205
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2010
Practice Address - Country:US
Practice Address - Phone:301-232-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0008351208000000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty