Provider Demographics
NPI:1790763415
Name:PATAMASUCON, PISESPONG (MD)
Entity Type:Individual
Prefix:
First Name:PISESPONG
Middle Name:
Last Name:PATAMASUCON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3016 W CHARLESTON BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1973
Mailing Address - Country:US
Mailing Address - Phone:702-780-2315
Mailing Address - Fax:702-895-1014
Practice Address - Street 1:2055 N HIGH ST STE 380
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5503
Practice Address - Country:US
Practice Address - Phone:303-393-4300
Practice Address - Fax:303-832-7205
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2023-05-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO562512080P0208X
NV96962080P0208X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO11780118Medicaid
CO11780118Medicaid
NVCS10553OtherSTATE PHARMACY
NVCS10553OtherSTATE PHARMACY
NV002018273Medicaid
NVE58145Medicare UPIN
CO11780118Medicaid