Provider Demographics
NPI:1366908543
Name:PHAM, PETER (NP)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17311 ROSEWOOD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2343
Mailing Address - Country:US
Mailing Address - Phone:949-229-0854
Mailing Address - Fax:870-201-4413
Practice Address - Street 1:1100 W TOWN AND COUNTRY RD STE 1239
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4600
Practice Address - Country:US
Practice Address - Phone:949-229-0854
Practice Address - Fax:870-201-4413
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95181593163W00000X
FL11021928363LP0808X
OR10031892363LP0808X
TX1170196363LP0808X
NV882787363LP0808X
CA95019677363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse