Healthcare Provider Details

I. General information

NPI: 1174808117
Provider Name (Legal Business Name): KHAMPHO THAMMAVONGXAY OHNO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4238 AUBURN WAY N
AUBURN WA
98002-1311
US

IV. Provider business mailing address

4238 AUBURN WAY N
AUBURN WA
98002-1311
US

V. Phone/Fax

Practice location:
  • Phone: 253-444-0106
  • Fax:
Mailing address:
  • Phone: 253-444-0106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 60250454
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-84
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: