Provider Demographics
NPI:1962764290
Name:SOUKAROON, PANUMAS (OTR/L)
Entity type:Individual
Prefix:
First Name:PANUMAS
Middle Name:
Last Name:SOUKAROON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 GLENWOOD SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9291
Mailing Address - Country:US
Mailing Address - Phone:916-752-0033
Mailing Address - Fax:
Practice Address - Street 1:GLENWOOD SPRINGS WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747
Practice Address - Country:US
Practice Address - Phone:916-752-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT12643208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation