Healthcare Provider Details

I. General information

NPI: 1851223721
Provider Name (Legal Business Name): PATRICK PHANTHANUSORN PPS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PASEO WESTPARK
IRVINE CA
92614-5311
US

IV. Provider business mailing address

5050 BARRANCA PKWY
IRVINE CA
92604-4652
US

V. Phone/Fax

Practice location:
  • Phone: 949-936-8615
  • Fax:
Mailing address:
  • Phone: 949-936-8615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: