Provider Demographics
NPI:1568919256
Name:RUNGRUANGPHOL, PATRA DEAR
Entity Type:Individual
Prefix:MISS
First Name:PATRA
Middle Name:DEAR
Last Name:RUNGRUANGPHOL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10124 RITA RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-2618
Mailing Address - Country:US
Mailing Address - Phone:214-734-3844
Mailing Address - Fax:
Practice Address - Street 1:13737 NOEL RD
Practice Address - Street 2:SUITE 1400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-1331
Practice Address - Country:US
Practice Address - Phone:214-754-8700
Practice Address - Fax:877-764-3083
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33063390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program