1972022762 NPI number — MR. PHOKHAM MIKE SOURIVANH PA-C

Table of content: MR. PHOKHAM MIKE SOURIVANH PA-C (NPI 1972022762)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972022762 NPI number — MR. PHOKHAM MIKE SOURIVANH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOURIVANH
Provider First Name:
PHOKHAM
Provider Middle Name:
MIKE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972022762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
CAMP PENDLETON
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
92055
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CAMP PENDLETON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
92055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-725-1288
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com