Basic Information
| Provider Information | |||||||||
| NPI: | 1386793925 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | NGA | ||||||||
| MiddleName: | ATHENA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 TAYLOR RD | ||||||||
| Address2: | STE 800 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361173551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 TAYLOR RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361173521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342731122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 08/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 20145 | AL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 51033969 | 01 | AL | BLUE CROSS | OTHER |