Provider Demographics
NPI:1124057831
Name:NINGSOMBOON, CHUTIMA (PAC)
Entity type:Individual
Prefix:
First Name:CHUTIMA
Middle Name:
Last Name:NINGSOMBOON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10316 WOODLEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-6916
Mailing Address - Country:US
Mailing Address - Phone:818-368-5651
Mailing Address - Fax:818-363-4770
Practice Address - Street 1:10316 WOODLEY AVE
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6916
Practice Address - Country:US
Practice Address - Phone:818-368-5651
Practice Address - Fax:818-363-4770
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17271OtherPAC LICENSE