Provider Demographics
NPI:1487209607
Name:IAMPHATCHARAWUT, MONGKHON
Entity Type:Individual
Prefix:
First Name:MONGKHON
Middle Name:
Last Name:IAMPHATCHARAWUT
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 1:1310 CLUB DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1187
Mailing Address - Country:US
Mailing Address - Phone:707-638-5970
Mailing Address - Fax:
Practice Address - Street 1:1121 124TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-2101
Practice Address - Country:US
Practice Address - Phone:425-455-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
WAPH61398138183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No174H00000XOther Service ProvidersHealth Educator