Provider Demographics
NPI:1053298406
Name:PHAM, JONATHAN (FNP-BC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:PHAM
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12772 9TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5406
Mailing Address - Country:US
Mailing Address - Phone:714-787-7567
Mailing Address - Fax:
Practice Address - Street 1:17150 EUCLID ST STE 200
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4092
Practice Address - Country:US
Practice Address - Phone:714-395-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily