Provider Demographics
NPI:1891771085
Name:PHAM, JUDY U (PA)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:U
Last Name:PHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:410-543-7536
Mailing Address - Fax:
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801
Practice Address - Country:US
Practice Address - Phone:410-543-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030319363A00000X
MDC0002525363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1891771085OtherNPI 1891771085
145724700OtherDEDERAL WORKMAN'S COMPENSATION DEPT. OF LABOR
251143OtherKAISER
131599Medicare PIN
145724700OtherDEDERAL WORKMAN'S COMPENSATION DEPT. OF LABOR
Q37400Medicare UPIN