Provider Demographics
NPI:1386130102
Name:SUTTHATARN, PATTAMON (MD)
Entity type:Individual
Prefix:MISS
First Name:PATTAMON
Middle Name:
Last Name:SUTTHATARN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 LINDELL BLVD APT 3037
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3280
Mailing Address - Country:US
Mailing Address - Phone:314-782-0489
Mailing Address - Fax:
Practice Address - Street 1:1465 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1003
Practice Address - Country:US
Practice Address - Phone:314-782-0489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180075532086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery