Healthcare Provider Details

I. General information

NPI: 1710395058
Provider Name (Legal Business Name): PROMPORN JUNE SUWANABOL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 HOSPITAL DR SUITE 2009
WATERTOWN WI
53098-3331
US

IV. Provider business mailing address

123 HOSPITAL DR SUITE 2009
WATERTOWN WI
53098-3331
US

V. Phone/Fax

Practice location:
  • Phone: 920-262-9833
  • Fax:
Mailing address:
  • Phone: 920-262-9833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3398-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: