Provider Demographics
NPI:1922732999
Name:LERTPAICHAIYON, SRIPATRA PATRA (PA-S)
Entity Type:Individual
Prefix:
First Name:SRIPATRA
Middle Name:PATRA
Last Name:LERTPAICHAIYON
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 HORIZON DR APT 406
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81506-1453
Mailing Address - Country:US
Mailing Address - Phone:310-945-6397
Mailing Address - Fax:
Practice Address - Street 1:1111 HORIZON DR APT 406
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-1453
Practice Address - Country:US
Practice Address - Phone:310-945-6397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program