Provider Demographics
NPI:1619555190
Name:PHAM, ALISA
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name: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 1:171 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:HARPERS FERRY
Mailing Address - State:WV
Mailing Address - Zip Code:25425-3641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 FOUNDATION WAY
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-9000
Practice Address - Country:US
Practice Address - Phone:304-264-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program