Provider Demographics
NPI:1093203176
Name:LAOCHAREUN, ANIRAPHONE
Entity Type:Individual
Prefix:
First Name:ANIRAPHONE
Middle Name:
Last Name:LAOCHAREUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 E RED BIRD LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75241-2008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1251 E RED BIRD LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241-2008
Practice Address - Country:US
Practice Address - Phone:214-374-0827
Practice Address - Fax:214-374-0927
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA12000OtherTMB #