Provider Demographics
NPI:1043073133
Name:CHAIYAMART, PATTARAPHONGPAN
Entity type:Individual
Prefix:
First Name:PATTARAPHONGPAN
Middle Name:
Last Name:CHAIYAMART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 CENTRAL AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4728
Mailing Address - Country:US
Mailing Address - Phone:612-239-8235
Mailing Address - Fax:
Practice Address - Street 1:1048 CENTRAL AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4728
Practice Address - Country:US
Practice Address - Phone:612-239-8235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2489704163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice