Provider Demographics
NPI:1427456615
Name:PHAM, TRUNG TAN
Entity type:Individual
Prefix:
First Name:TRUNG
Middle Name:TAN
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 1:8257 HOPEWELL DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-6287
Mailing Address - Country:US
Mailing Address - Phone:916-686-6802
Mailing Address - Fax:
Practice Address - Street 1:8257 HOPEWELL DR
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-6287
Practice Address - Country:US
Practice Address - Phone:916-686-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-20
Last Update Date:2014-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist