MEDICARE: DR. PHACHARAWUT KANCHANANAKHIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	A91630	CA

General Provider Information

NPI Number	:	1114031721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHACHARAWUT KANCHANANAKHIN MD

Provider Business Mailing Address
First Line	:	5040 WOODSPRING CT
Second Line	:	SUITE 160
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-8838
Country	:	US
Telephone Number	:	916-576-7898
Fax Number	:	916-285-0338

Provider Business Practice Location Address
First Line	:	1712 PICASSO AVE
Second Line	:	SUITE D
City	:	DAVIS
State	:	CA
Zip	:	95618-0546
Country	:	US
Telephone Number	:	916-576-7898
Fax Number	:	916-285-0338

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2006
Last Update Date	:	10/04/2016

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