Provider Demographics
NPI:1770131732
Name:PHAM, THAO HIEU (PA-C)
Entity type:Individual
Prefix:MS
First Name:THAO
Middle Name:HIEU
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 1:2283 CHRISTIAN CIR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-5207
Mailing Address - Country:US
Mailing Address - Phone:404-422-0180
Mailing Address - Fax:
Practice Address - Street 1:3985 STEVE REYNOLDS BLVD STE K102
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-3099
Practice Address - Country:US
Practice Address - Phone:678-367-0390
Practice Address - Fax:678-245-3391
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-03
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9423207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty