Provider Demographics
NPI:1376922799
Name:SYRAVANH, CHANHSAMONE (PA)
Entity Type:Individual
Prefix:
First Name:CHANHSAMONE
Middle Name:
Last Name:SYRAVANH
Suffix:
Gender:M
Credentials:PA
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Other - Credentials:
Mailing Address - Street 1:4745 OGLETOWN STANTON RD
Mailing Address - Street 2:MEDICAL ARTS PAVILION 1, SUITE 135, HOSMANE CARDIOLOGY
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2067
Mailing Address - Country:US
Mailing Address - Phone:302-292-3541
Mailing Address - Fax:302-292-3542
Practice Address - Street 1:4745 OGLETOWN STANTON RD
Practice Address - Street 2:MEDICAL ARTS PAVILION 1, SUITE 135, HOSMANE CARDIOLOGY
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2067
Practice Address - Country:US
Practice Address - Phone:302-292-3541
Practice Address - Fax:302-292-3542
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-19
Last Update Date:2015-05-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
DEC5-0000559363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical