Provider Demographics
NPI:1972022762
Name:SOURIVANH, PHOKHAM MIKE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PHOKHAM
Middle Name:MIKE
Last Name:SOURIVANH
Suffix:
Gender:M
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:CAMP PENDLETON
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CAMP PENDLETON
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-1288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider