Provider Demographics
NPI:1720108830
Name:PHOMMATHA, SONEMALA (PA-C)
Entity type:Individual
Prefix:MISS
First Name:SONEMALA
Middle Name:
Last Name:PHOMMATHA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 E 19TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1242
Mailing Address - Country:US
Mailing Address - Phone:303-762-3472
Mailing Address - Fax:
Practice Address - Street 1:1721 E 19TH AVE STE 500
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1242
Practice Address - Country:US
Practice Address - Phone:303-762-3472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0002374363A00000X, 363AS0400X, 363AS0400X
CO2374363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX188291201Medicaid
TX8Y2613OtherBLUE CROSS BLUE SHIELD
TX8J9678Medicare PIN