Provider Demographics
NPI:1225793987
Name:SOMPHONPHAKDY, ANDREW PHETAROUN
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:PHETAROUN
Last Name:SOMPHONPHAKDY
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 1:13229 EDWARDS RD
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1823
Mailing Address - Country:US
Mailing Address - Phone:562-587-0978
Mailing Address - Fax:
Practice Address - Street 1:13229 EDWARDS RD
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1823
Practice Address - Country:US
Practice Address - Phone:562-587-0978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant