Provider Demographics
NPI:1588454516
Name:PHAM, PHUONG NHU THI (PA-C)
Entity type:Individual
Prefix:
First Name:PHUONG
Middle Name:NHU THI
Last Name:PHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10258 SOUTHWEST HWY STE A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-1361
Mailing Address - Country:US
Mailing Address - Phone:708-346-9533
Mailing Address - Fax:
Practice Address - Street 1:10258 SOUTHWEST HWY STE A
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1361
Practice Address - Country:US
Practice Address - Phone:708-346-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-12
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085011147363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant