Provider Demographics
NPI:1245507482
Name:MUNGSAWAT, PATHCHARAPORN (LMP)
Entity type:Individual
Prefix:MRS
First Name:PATHCHARAPORN
Middle Name:
Last Name:MUNGSAWAT
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ALGONA
Mailing Address - State:WA
Mailing Address - Zip Code:98001-7443
Mailing Address - Country:US
Mailing Address - Phone:360-713-4714
Mailing Address - Fax:
Practice Address - Street 1:921 N 1ST ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-5760
Practice Address - Country:US
Practice Address - Phone:360-713-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60160236225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist