Provider Demographics
NPI:1538113121
Name:HAISUPA, APICHAI (MPT)
Entity Type:Individual
Prefix:
First Name:APICHAI
Middle Name:
Last Name:HAISUPA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:OLE
Other - Middle Name:
Other - Last Name:HAISUPA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT
Mailing Address - Street 1:4104 RUBICON PEAK CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-3673
Mailing Address - Country:US
Mailing Address - Phone:702-656-2117
Mailing Address - Fax:
Practice Address - Street 1:2851 N TENAYA WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0453
Practice Address - Country:US
Practice Address - Phone:702-655-9456
Practice Address - Fax:702-655-9594
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV39358Medicare ID - Type Unspecified