Healthcare Provider Details

I. General information

NPI: 1477488476
Provider Name (Legal Business Name): PONLORK CHHORN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2026
Last Update Date: 06/13/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13182 BLUE SPRUCE AVE
GARDEN GROVE CA
92840-6043
US

IV. Provider business mailing address

13182 BLUE SPRUCE AVE
GARDEN GROVE CA
92840-6043
US

V. Phone/Fax

Practice location:
  • Phone: 714-697-9890
  • Fax:
Mailing address:
  • Phone: 714-697-9890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: