Provider Demographics
NPI:1942738943
Name:VERMILLION, SOPHAVY SUON (PA-C)
Entity Type:Individual
Prefix:
First Name:SOPHAVY
Middle Name:SUON
Last Name:VERMILLION
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SOPHAVY
Other - Middle Name:
Other - Last Name:SUON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3650 SUNSET BLVD
Mailing Address - Street 2:#69
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027
Mailing Address - Country:US
Mailing Address - Phone:323-361-7651
Mailing Address - Fax:
Practice Address - Street 1:3650 SUNSET BLVD
Practice Address - Street 2:#69
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:323-361-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54512363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical