Provider Demographics
NPI:1245705086
Name:PHAM, RYAN DUY
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DUY
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11744 SUMMERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-2668
Mailing Address - Country:US
Mailing Address - Phone:714-401-8579
Mailing Address - Fax:
Practice Address - Street 1:2075 SAN JOAQUIN HILLS RD
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-6505
Practice Address - Country:US
Practice Address - Phone:949-760-9222
Practice Address - Fax:949-579-2906
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant