Provider Demographics
NPI:1952085276
Name:PHAN, TIN TRUNG
Entity Type:Individual
Prefix:
First Name:TIN
Middle Name:TRUNG
Last Name:PHAN
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 1:504 SPRING HILL DR STE 420
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77386-6029
Mailing Address - Country:US
Mailing Address - Phone:183-229-3795
Mailing Address - Fax:
Practice Address - Street 1:504 SPRING HILL DR STE 420
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77386-6029
Practice Address - Country:US
Practice Address - Phone:713-385-6974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT026763225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist