MEDICARE: SOPHAVY SUON VERMILLION PA-C

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	363AM0700X	Medical Physician Assistant	54512	CA
2	363AM0700X	Medical Physician Assistant	PA19411	TX

General Provider Information

NPI Number	:	1942738943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHAVY SUON VERMILLION PA-C

Provider Business Mailing Address
First Line	:	7200 CAMBRIDGE ST STE 10A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-4202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7200 CAMBRIDGE ST FL 10
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-4202
Country	:	US
Telephone Number	:	713-986-6016
Fax Number	:

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

Provider Enumeration Date	:	06/02/2017
Last Update Date	:	01/23/2026

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Directions to “ SOPHAVY SUON VERMILLION PA-C” Practice Location

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