Basic Information
| Provider Information | |||||||||
| NPI: | 1235753963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | NGHIEM | ||||||||
| MiddleName: | XUAN | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | PHAM | ||||||||
| OtherFirstName: | JAY | ||||||||
| OtherMiddleName: | XUAN | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4013 LITCHFIELD DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238327821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063037447 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232985058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8048289783 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2020 | ||||||||
| LastUpdateDate: | 05/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.