Provider Demographics
NPI:1972924496
Name:PHAM, THANH-DIU THI (PA-C)
Entity Type:Individual
Prefix:
First Name:THANH-DIU
Middle Name:THI
Last Name: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 1:100 E LIBERTY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1434
Mailing Address - Country:US
Mailing Address - Phone:502-367-3360
Mailing Address - Fax:502-367-3365
Practice Address - Street 1:2206 N JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-1776
Practice Address - Country:US
Practice Address - Phone:936-671-4300
Practice Address - Fax:936-671-4323
Is Sole Proprietor?:No
Enumeration Date:2013-12-31
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9052363AM0700X, 363AM0700X
KYPA2162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100438310Medicaid
KYK227780Medicare PIN