Provider Demographics
NPI:1023646882
Name:PHO, CHHORN HOUN (PA-C)
Entity type:Individual
Prefix:MS
First Name:CHHORN
Middle Name:HOUN
Last Name:PHO
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 1:1200 167TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-2854
Mailing Address - Country:US
Mailing Address - Phone:651-528-3713
Mailing Address - Fax:
Practice Address - Street 1:22978 BUTTERFIELD DR NW
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:MN
Practice Address - Zip Code:55070-7710
Practice Address - Country:US
Practice Address - Phone:763-230-9248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN132492084P0800X, 363A00000X
WA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner