Provider Demographics
NPI:1255609913
Name:PHAM, TAM-THAO THI (NP)
Entity type:Individual
Prefix:
First Name:TAM-THAO
Middle Name:THI
Last Name:PHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7514 GIRARD AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5149
Mailing Address - Country:US
Mailing Address - Phone:858-754-1114
Mailing Address - Fax:800-490-3126
Practice Address - Street 1:7514 GIRARD AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5149
Practice Address - Country:US
Practice Address - Phone:858-754-1114
Practice Address - Fax:800-490-3126
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-09
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP20608363L00000X
CANP 20608363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily