Healthcare Provider Details

I. General information

NPI: 1528770625
Provider Name (Legal Business Name): PORNCHANOK TAM KHEOCHA-ON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 RESERVOIR RD NW
WASHINGTON DC
20007-2113
US

IV. Provider business mailing address

6291 HILLARY CT
ALEXANDRIA VA
22315-3440
US

V. Phone/Fax

Practice location:
  • Phone: 202-444-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberNP1041368
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP1041368
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: