| Doctor Name: | STACEY THAO PHAN |
| NPI Number: | 1235263385 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | D.O. |
| License Number: | |
| Business Practice Address: | 1300 Franklin Ave Ste 100 Normal, IL - 617613676 |
| Business Phone Number: | 3092683455 |
| Business Fax Number: | 3092685620 |
| Mailing Address: | 6801 Green Meadow Ln, OKLAHOMA CITY |
| State: | OK |
| Postal Code: | 731323957 |
| Phone Number: | 4052450747 |
| Fax Number: | |
| NPI Enumeration Date: | 03/14/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |