Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 049706 | GA |
NPI | 1003808312 |
---|---|
Provider Name | Dr. Truc Thanh Pham |
First Address | Norcross, GA 30093-3035 |
Second Address | Norcross, GA 30093-3035 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/08/2005 |
Last Update Date | 16/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
52070574-001 | BLUE CROSS BLUE SHIELD ID (01) | GA |
844204821A | (05) | GA |
844204821B | (05) | GA |
H98477 | (02) | GA |