Provider Demographics
NPI:1316723570
Name:PHAM, KIM N (PA-C)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:N
Last Name:PHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7679
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7679
Practice Address - Country:US
Practice Address - Phone:718-518-5814
Practice Address - Fax:718-579-3929
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA065286363A00000X
NY030968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant