Provider Demographics
NPI:1689607780
Name:PHAM-VANG, SANDY (OD)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:
Last Name:PHAM-VANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11217 COMMERCE DR N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-3122
Mailing Address - Country:US
Mailing Address - Phone:763-427-5474
Mailing Address - Fax:
Practice Address - Street 1:11217 COMMERCE DR N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-3122
Practice Address - Country:US
Practice Address - Phone:763-427-5474
Practice Address - Fax:952-346-2176
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3056152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management