Provider Demographics
NPI:1720508542
Name:PHAM, KHANH TRUC (PA-C)
Entity Type:Individual
Prefix:
First Name:KHANH
Middle Name:TRUC
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 1:11122 CREEKLINE GLEN CT
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-3675
Mailing Address - Country:US
Mailing Address - Phone:832-533-4163
Mailing Address - Fax:
Practice Address - Street 1:11122 CREEKLINE GLEN CT.
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429
Practice Address - Country:US
Practice Address - Phone:832-533-4163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant