Provider Demographics
NPI:1710395058
Name:SUWANABOL, PROMPORN JUNE
Entity Type:Individual
Prefix:
First Name:PROMPORN
Middle Name:JUNE
Last Name:SUWANABOL
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 1:123 HOSPITAL DR
Mailing Address - Street 2:SUITE 2009
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3331
Mailing Address - Country:US
Mailing Address - Phone:920-262-9833
Mailing Address - Fax:
Practice Address - Street 1:123 HOSPITAL DR
Practice Address - Street 2:SUITE 2009
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3331
Practice Address - Country:US
Practice Address - Phone:920-262-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3398-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical