Basic Information
| Provider Information | |||||||||
| NPI: | 1609413830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | MINHANH | ||||||||
| MiddleName: | TRINH | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 949 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301620949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042614414 | ||||||||
| FaxNumber: | 9042614614 | ||||||||
| Practice Location | |||||||||
| Address1: | 463646 STATE ROAD 200 STE 4 | ||||||||
| Address2: | |||||||||
| City: | YULEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320970303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042614414 | ||||||||
| FaxNumber: | 9042614614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2019 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9983 | SC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT36205 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.