Provider Demographics
NPI:1780074575
Name:PATHOOMVANH, MEGAN (ATC, VATL)
Entity type:Individual
Prefix:MISS
First Name:MEGAN
Middle Name:
Last Name:PATHOOMVANH
Suffix:
Gender:F
Credentials:ATC, VATL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4233 LLEWELLYN AVE
Mailing Address - Street 2:APT 108
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-1132
Mailing Address - Country:US
Mailing Address - Phone:401-222-9476
Mailing Address - Fax:
Practice Address - Street 1:6501 CHESAPEAKE BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23513-1974
Practice Address - Country:US
Practice Address - Phone:401-222-9476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-31
Last Update Date:2015-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260021782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer