Provider Demographics
NPI:1386793925
Name:PHAN, ATHENA NGA (MD)
Entity type:Individual
Prefix:DR
First Name:ATHENA
Middle Name:NGA
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 MITYLENE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3548
Mailing Address - Country:US
Mailing Address - Phone:334-273-1122
Mailing Address - Fax:334-273-7837
Practice Address - Street 1:202 MITYLENE PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3548
Practice Address - Country:US
Practice Address - Phone:205-801-8378
Practice Address - Fax:334-273-7837
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20145207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51033969OtherBLUE CROSS
AL51033969OtherBLUE CROSS
ALE25048Medicare UPIN