Provider Demographics
NPI:1245334630
Name:PHAN, TRICIA (OD)
Entity type:Individual
Prefix:MISS
First Name:TRICIA
Middle Name:
Last Name:PHAN
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 1:4051 TACOMA MALL BLVD
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7287
Mailing Address - Country:US
Mailing Address - Phone:253-473-6427
Mailing Address - Fax:253-473-9165
Practice Address - Street 1:4051 TACOMA MALL BLVD
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7287
Practice Address - Country:US
Practice Address - Phone:253-473-6427
Practice Address - Fax:253-473-9165
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60176880152W00000X
CA12852 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist