Provider Demographics
NPI:1518158047
Name:SUNTALUS, CHANUWAT M (PA-C)
Entity Type:Individual
Prefix:
First Name:CHANUWAT
Middle Name:M
Last Name:SUNTALUS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 MONTE VISTA AVE STE 190
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-6600
Mailing Address - Country:US
Mailing Address - Phone:626-617-9166
Mailing Address - Fax:909-469-2119
Practice Address - Street 1:1601 MONTE VISTA AVE STE 190
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-6600
Practice Address - Country:US
Practice Address - Phone:909-865-9977
Practice Address - Fax:909-469-2119
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17843363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1518158047Medicaid