Provider Demographics
NPI:1174791248
Name:MILLARD, VIPAPORN SERIBURI (PA-C)
Entity type:Individual
Prefix:
First Name:VIPAPORN
Middle Name:SERIBURI
Last Name:MILLARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VIPAPORN
Other - Middle Name:
Other - Last Name:MILLARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2425 BEL PRE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-2309
Mailing Address - Country:US
Mailing Address - Phone:410-960-9439
Mailing Address - Fax:
Practice Address - Street 1:8206 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4519
Practice Address - Country:US
Practice Address - Phone:301-960-4682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003544363A00000X
OH35.096586363AS0400X
ORPA171841363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant