Provider Demographics
NPI:1992559363
Name:PHAM, NICHOLAS QUANG (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:QUANG
Last Name:PHAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5528 LAVACA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-8566
Mailing Address - Country:US
Mailing Address - Phone:469-928-5714
Mailing Address - Fax:
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-947-2306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10089119390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program