Provider Demographics
NPI:1164585691
Name:KHAMPANE, THOTSAPHONE (PAC)
Entity Type:Individual
Prefix:MR
First Name:THOTSAPHONE
Middle Name:
Last Name:KHAMPANE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3043
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3043
Mailing Address - Country:US
Mailing Address - Phone:630-734-0200
Mailing Address - Fax:
Practice Address - Street 1:AURORA SINAI MEDICAL CENTER
Practice Address - Street 2:945 NORTH 12TH ST
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233
Practice Address - Country:US
Practice Address - Phone:414-219-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI822-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant