Provider Demographics
NPI:1891869210
Name:PHAM, NGOC MINH (PA)
Entity Type:Individual
Prefix:
First Name:NGOC
Middle Name:MINH
Last Name:PHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4120 W MEMORIAL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9320
Mailing Address - Country:US
Mailing Address - Phone:405-748-3300
Mailing Address - Fax:405-749-1671
Practice Address - Street 1:825 NE 10TH ST
Practice Address - Street 2:OUPB 4500
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5417
Practice Address - Country:US
Practice Address - Phone:405-271-5789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18067363A00000X
OKPA1573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK249708602Medicare PIN