MEDICARE: DAOSAMAY SITDAMLONG PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1124784608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAOSAMAY SITDAMLONG PA-C

Provider Business Mailing Address
First Line	:	2366 STOREN ST
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9039
Country	:	US
Telephone Number	:	414-299-8414
Fax Number	:

Provider Business Practice Location Address
First Line	:	2366 STOREN ST
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9039
Country	:	US
Telephone Number	:	414-299-8414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2021
Last Update Date	:	11/09/2021

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