Provider Demographics
NPI:1780370452
Name:PHAM, ANGEL
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1894 MERCHANTS ROW BLVD APT 2511
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-8806
Mailing Address - Country:US
Mailing Address - Phone:502-804-6717
Mailing Address - Fax:
Practice Address - Street 1:1894 MERCHANTS ROW BLVD APT 2511
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32311-8806
Practice Address - Country:US
Practice Address - Phone:502-804-6717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA893367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant