Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN1001X | Nutrition | 3532 | MN |
NPI | 1093713711 |
---|---|
Provider Name | Dr. Susan H. Pham |
First Address | Saint Paul, MN 55104-4796 |
Second Address | Saint Paul, MN 55104-4796 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
232018 | ACN (01) | MN |
5C969 PH | BCBS-MN (01) | MN |
U79158 | (02) | MN |