Provider Demographics
NPI:1215319546
Name:PHAM, LIEN MY (PA-C)
Entity type:Individual
Prefix:
First Name:LIEN
Middle Name:MY
Last Name:PHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2037 VISTA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5081
Mailing Address - Country:US
Mailing Address - Phone:714-823-6442
Mailing Address - Fax:
Practice Address - Street 1:4455 W 117TH ST STE 300
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-2240
Practice Address - Country:US
Practice Address - Phone:310-645-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant