Provider Demographics
NPI:1275553760
Name:SAKOUNPHONG, AROUNRATSAMI (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MISS
First Name:AROUNRATSAMI
Middle Name:
Last Name:SAKOUNPHONG
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MISS
Other - First Name:AROUNRATSAMI
Other - Middle Name:
Other - Last Name:SAKOUNPHONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:1571 W SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-3333
Mailing Address - Country:US
Mailing Address - Phone:213-482-4400
Mailing Address - Fax:213-482-5150
Practice Address - Street 1:1574 W BASE LINE ST STE 107
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1736
Practice Address - Country:US
Practice Address - Phone:909-386-1880
Practice Address - Fax:909-386-1882
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16271Medicaid