Healthcare Provider Details

I. General information

NPI: 1972022762
Provider Name (Legal Business Name): PHOKHAM MIKE SOURIVANH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NMRTC PENSACOLA 6000 WEST HIGHWAY 98
PENSACOLA FL
32512-0001
US

IV. Provider business mailing address

CAMP PENDLETON
APO AP
92055
US

V. Phone/Fax

Practice location:
  • Phone: 901-874-6081
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: