Provider Demographics
NPI:1144529462
Name:MAK, THY ANH TUAN PHAN (PA-C)
Entity type:Individual
Prefix:
First Name:THY
Middle Name:ANH TUAN PHAN
Last Name:MAK
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 1:6400 FANNIN ST STE 2070
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1541
Mailing Address - Country:US
Mailing Address - Phone:713-486-7747
Mailing Address - Fax:
Practice Address - Street 1:925 GESSNER RD STE 100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2545
Practice Address - Country:US
Practice Address - Phone:713-242-3500
Practice Address - Fax:713-984-6825
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00964720OtherRR MEDICARE
TX847N07OtherBCBS
TX220114701Medicaid
TX847N07OtherBCBS