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 1:8759 HASTINGS CIR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4508
Mailing Address - Country:US
Mailing Address - Phone:651-528-3713
Mailing Address - Fax:
Practice Address - Street 1:8649 MARTIN WAY E
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-5812
Practice Address - Country:US
Practice Address - Phone:651-528-3713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225400000X
MN132492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner