Provider Demographics
NPI:1770276974
Name:PHAM, KHOAMARTIN DANG
Entity type:Individual
Prefix:
First Name:KHOAMARTIN
Middle Name:DANG
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 1:12201 HIDDEN RIVER LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-6531
Mailing Address - Country:US
Mailing Address - Phone:832-659-5893
Mailing Address - Fax:
Practice Address - Street 1:6720 BERTNER AVE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2604
Practice Address - Country:US
Practice Address - Phone:832-355-2666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX789789865367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant