Healthcare Provider Details

I. General information

NPI: 1023646882
Provider Name (Legal Business Name): CHHORN HOUN PHO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22978 BUTTERFIELD DR NW
SAINT FRANCIS MN
55070-7710
US

IV. Provider business mailing address

1200 167TH AVE NW
ANDOVER MN
55304-2854
US

V. Phone/Fax

Practice location:
  • Phone: 763-230-9248
  • Fax:
Mailing address:
  • Phone: 651-528-3713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13249
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number13249
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: