Provider Demographics
NPI:1043095862
Name:NGUYEN-PHAM, KATHY
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:NGUYEN-PHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 FOURTH AVE STE 505
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2121
Mailing Address - Country:US
Mailing Address - Phone:619-298-1318
Mailing Address - Fax:619-298-0843
Practice Address - Street 1:4060 FOURTH AVE STE 505
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2121
Practice Address - Country:US
Practice Address - Phone:619-298-1318
Practice Address - Fax:619-298-0843
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty