Provider Demographics
NPI:1417030081
Name:CHITASOMBAT, TIPARPA (CNS)
Entity Type:Individual
Prefix:
First Name:TIPARPA
Middle Name:
Last Name:CHITASOMBAT
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:TIPARPA
Other - Middle Name:
Other - Last Name:RUNGSEEVONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5463
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:451 NORTH DUNLAP STREET
Practice Address - Street 2:MAIL STOP 32700A
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4621
Practice Address - Country:US
Practice Address - Phone:651-999-4700
Practice Address - Fax:651-999-4781
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1307223364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist