Provider Demographics
NPI:1942488374
Name:HOMIAK, PHORNPHAN MOLTANE (PA-C)
Entity Type:Individual
Prefix:
First Name:PHORNPHAN
Middle Name:MOLTANE
Last Name:HOMIAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 BURKE CENTRE PKWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3750
Mailing Address - Country:US
Mailing Address - Phone:703-425-6010
Mailing Address - Fax:703-425-7504
Practice Address - Street 1:6035 BURKE CENTRE PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3750
Practice Address - Country:US
Practice Address - Phone:703-425-6010
Practice Address - Fax:703-425-7504
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103810363A00000X
VA0110004437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant