Provider Demographics
NPI:1053551499
Name:PHAM, MAI LIEN (DO)
Entity type:Individual
Prefix:DR
First Name:MAI
Middle Name:LIEN
Last Name:PHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HOSPITAL LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD AIR FORCE BASE
Mailing Address - State:WA
Mailing Address - Zip Code:99011-8704
Mailing Address - Country:US
Mailing Address - Phone:509-247-5755
Mailing Address - Fax:
Practice Address - Street 1:701 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AIR FORCE BASE
Practice Address - State:WA
Practice Address - Zip Code:99011-8704
Practice Address - Country:US
Practice Address - Phone:509-247-5755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-25
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5025207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine