Provider Demographics
NPI:1528250701
Name:PHAN, THANH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:THANH
Middle Name:
Last Name:PHAN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15950 ELDORADO PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-5816
Mailing Address - Country:US
Mailing Address - Phone:214-390-5388
Mailing Address - Fax:972-547-0513
Practice Address - Street 1:15950 ELDORADO PKWY
Practice Address - Street 2:STE 400
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-5802
Practice Address - Country:US
Practice Address - Phone:214-390-5388
Practice Address - Fax:972-547-0513
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05186363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant