Provider Demographics
NPI:1548264252
Name:PHAM, LAN N (MD)
Entity type:Individual
Prefix:MR
First Name:LAN
Middle Name:N
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 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT. 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-501-3601
Practice Address - Fax:360-501-3648
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037318207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0256048OtherWASHINGTON DOL
WA8248452Medicaid
WAGAB13158Medicare PIN
WA0256048OtherWASHINGTON DOL
WA8248452Medicaid
WAG8879056Medicare PIN