Provider Demographics
NPI:1124784608
Name:SITDAMLONG, DAOSAMAY (PA-C)
Entity type:Individual
Prefix:
First Name:DAOSAMAY
Middle Name:
Last Name:SITDAMLONG
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 1:2366 STOREN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9039
Mailing Address - Country:US
Mailing Address - Phone:414-299-8414
Mailing Address - Fax:
Practice Address - Street 1:2366 STOREN ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9039
Practice Address - Country:US
Practice Address - Phone:414-299-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant