Provider Demographics
NPI:1528511573
Name:PHAM, ANGIE NGUYEN (OD)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:NGUYEN
Last Name:PHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22528 100TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-3243
Mailing Address - Country:US
Mailing Address - Phone:206-267-8934
Mailing Address - Fax:
Practice Address - Street 1:2510 N PROCTOR ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-5338
Practice Address - Country:US
Practice Address - Phone:253-525-2020
Practice Address - Fax:253-301-1228
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60671639152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist