Basic Information
| Provider Information | |||||||||
| NPI: | 1952052755 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAM | ||||||||
| FirstName: | ROBYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 619 NW 6TH AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972093964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039887468 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9000 N LOMBARD ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972033006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039885304 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2022 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 202112104RN | OR | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 202214125NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 022959 | 05 | OR | MEDICAID |