Provider Demographics
NPI:1124739354
Name:PISARNWONGS, VOOTTISIN MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:VOOTTISIN
Middle Name:MICHAEL
Last Name:PISARNWONGS
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 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 CONGRESS ST STE 210
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3027
Practice Address - Country:US
Practice Address - Phone:626-995-4447
Practice Address - Fax:424-314-0550
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA62297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant