Provider Demographics
NPI:1801612304
Name:PHAM, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:849 N MCCADDEN PL # 20
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-3426
Mailing Address - Country:US
Mailing Address - Phone:281-203-9727
Mailing Address - Fax:
Practice Address - Street 1:849 N MCCADDEN PL # 20
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-3426
Practice Address - Country:US
Practice Address - Phone:281-203-9727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-29
Last Update Date:2025-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant