Healthcare Provider Details

I. General information

NPI: 1790353654
Provider Name (Legal Business Name): INKKARUCH KUPRASERTKUL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 PRINGLE WAY STE 706
RENO NV
89502-1472
US

IV. Provider business mailing address

1155 MILL ST # M14
RENO NV
89502-1576
US

V. Phone/Fax

Practice location:
  • Phone: 775-982-5000
  • Fax: 775-982-3900
Mailing address:
  • Phone: 775-982-5262
  • Fax: 775-982-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number29608
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: