Provider Demographics
NPI:1780259192
Name:PHAM, DIEMKIEU
Entity type:Individual
Prefix:
First Name:DIEMKIEU
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIEU
Other - Middle Name:
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2230 N RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-1053
Mailing Address - Country:US
Mailing Address - Phone:316-448-8339
Mailing Address - Fax:316-221-7149
Practice Address - Street 1:2230 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-1053
Practice Address - Country:US
Practice Address - Phone:316-448-8339
Practice Address - Fax:316-221-7149
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02552207Q00000X, 363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program