Provider Demographics
NPI:1508587676
Name:RUNGSISULLATANONT, RITT
Entity Type:Individual
Prefix:
First Name:RITT
Middle Name:
Last Name:RUNGSISULLATANONT
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 1:6619 VIA GANCHO CIR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-4117
Mailing Address - Country:US
Mailing Address - Phone:562-857-7302
Mailing Address - Fax:
Practice Address - Street 1:8700 WARNER AVE STE 140
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3209
Practice Address - Country:US
Practice Address - Phone:714-850-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant