Provider Demographics
NPI:1811659782
Name:PHAM, JASMINE
Entity type:Individual
Prefix:
First Name:JASMINE
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 1:1109 E HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-4812
Mailing Address - Country:US
Mailing Address - Phone:126-725-2906
Mailing Address - Fax:
Practice Address - Street 1:1109 E HUNTING PARK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-4812
Practice Address - Country:US
Practice Address - Phone:126-725-2906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP024475363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care