Provider Demographics
NPI:1851918692
Name:PHAM, KIM-TIEN QUOC (ARNP)
Entity Type:Individual
Prefix:
First Name:KIM-TIEN
Middle Name:QUOC
Last Name:PHAM
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-2623
Mailing Address - Country:US
Mailing Address - Phone:360-782-6000
Mailing Address - Fax:360-782-6099
Practice Address - Street 1:2709 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2623
Practice Address - Country:US
Practice Address - Phone:360-782-6000
Practice Address - Fax:360-782-6099
Is Sole Proprietor?:No
Enumeration Date:2020-06-27
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61073230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2165705Medicaid