Provider Demographics
NPI:1730799164
Name:PHAM, KIM-ANH NGOC (FNP-C)
Entity type:Individual
Prefix:
First Name:KIM-ANH
Middle Name:NGOC
Last Name:PHAM
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 WELLS AVE W
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-2806
Mailing Address - Country:US
Mailing Address - Phone:315-350-0695
Mailing Address - Fax:
Practice Address - Street 1:201 MONARCH DR
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-4506
Practice Address - Country:US
Practice Address - Phone:315-615-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
NY346281363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily