MEDICARE: PISESPONG PATAMASUCON M.D.

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	2080P0208X	Pediatric Infectious Diseases Physician	56251	CO
2	2080P0208X	Pediatric Infectious Diseases Physician	9696	NV

General Provider Information

NPI Number	:	1790763415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PISESPONG PATAMASUCON M.D.

Provider Business Mailing Address
First Line	:	3016 W CHARLESTON BLVD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1973
Country	:	US
Telephone Number	:	702-780-2315
Fax Number	:	702-895-1014

Provider Business Practice Location Address
First Line	:	1524 PINTO LN FL 3
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4195
Country	:	US
Telephone Number	:	702-944-2828
Fax Number	:	702-944-2852

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

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	02/10/2025

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Directions to “ PISESPONG PATAMASUCON M.D.” Practice Location

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