Provider Demographics
NPI:1639142219
Name:PHAM, CHRISTIAN
Entity type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
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 1:3353 WEMBLEY WALK
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2232
Mailing Address - Country:US
Mailing Address - Phone:770-493-9252
Mailing Address - Fax:
Practice Address - Street 1:405 ARROWHEAD BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1254
Practice Address - Country:US
Practice Address - Phone:770-478-9877
Practice Address - Fax:770-478-2908
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003450367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP10239Medicare UPIN
GA97BBFXZMedicare ID - Type UnspecifiedANESTHESIA