Provider Demographics
NPI:1538198221
Name:PHAM, THANH V (MD)
Entity type:Individual
Prefix:
First Name:THANH
Middle Name:V
Last Name:PHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30809 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-4074
Mailing Address - Country:US
Mailing Address - Phone:253-839-2030
Mailing Address - Fax:
Practice Address - Street 1:30809 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4074
Practice Address - Country:US
Practice Address - Phone:253-839-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038413207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA138971OtherSTATE L&I
WA156570OtherSTATE L&I
WA1044623Medicaid
WAGAB26703Medicare PIN
WAH16027Medicare UPIN
WAAB26703Medicare ID - Type Unspecified
WAGAB15514Medicare PIN