Provider Demographics
NPI:1912473273
Name:PHAM, TIEN T (APN, CNP)
Entity Type:Individual
Prefix:
First Name:TIEN
Middle Name:T
Last Name:PHAM
Suffix:
Gender:F
Credentials:APN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5016
Mailing Address - Country:US
Mailing Address - Phone:309-589-2050
Mailing Address - Fax:309-692-4730
Practice Address - Street 1:5405 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5016
Practice Address - Country:US
Practice Address - Phone:309-589-2050
Practice Address - Fax:309-692-4730
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017737363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner