Provider Demographics
NPI:1972141505
Name:PHAM, KRISTIN VO (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:VO
Last Name:PHAM
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10622 BOLSA AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-5202
Mailing Address - Country:US
Mailing Address - Phone:714-489-3568
Mailing Address - Fax:
Practice Address - Street 1:485 E 17TH ST STE 650
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-4706
Practice Address - Country:US
Practice Address - Phone:949-722-7374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT297779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist