Provider Demographics
NPI:1376769075
Name:ATICOMBUNTHIDKUL, ONANONG (PT)
Entity Type:Individual
Prefix:
First Name:ONANONG
Middle Name:
Last Name:ATICOMBUNTHIDKUL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 29TH ST # 2R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2821
Mailing Address - Country:US
Mailing Address - Phone:718-956-0096
Mailing Address - Fax:
Practice Address - Street 1:160 LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1103
Practice Address - Country:US
Practice Address - Phone:718-436-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0-14727-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist