Provider Demographics
NPI:1760800460
Name:THIRAKUL, PHOUTTHASONE
Entity Type:Individual
Prefix:
First Name:PHOUTTHASONE
Middle Name:
Last Name:THIRAKUL
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 1:11025 N 46TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2000
Mailing Address - Country:US
Mailing Address - Phone:813-914-4500
Mailing Address - Fax:
Practice Address - Street 1:11025 N 46TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-2000
Practice Address - Country:US
Practice Address - Phone:813-914-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA125018207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology