Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | P1128 | TX |
N | 207NS0135X | Procedural Dermatology | P1128 | TX |
NPI | 1407173230 |
---|---|
Provider Name | Ryan Pham |
First Address | Burleson, TX 76028-5833 |
Second Address | Burleson, TX 76028-5833 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/05/2010 |
Last Update Date | 28/11/2017 |