Provider Demographics
NPI:1174808117
Name:OHNO, KHAMPHO THAMMAVONGXAY
Entity type:Individual
Prefix:
First Name:KHAMPHO
Middle Name:THAMMAVONGXAY
Last Name:OHNO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 YPAO RD
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3701
Mailing Address - Country:US
Mailing Address - Phone:761-646-8881
Mailing Address - Fax:
Practice Address - Street 1:388 YPAO RD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3701
Practice Address - Country:US
Practice Address - Phone:761-646-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA 60250454363A00000X
GUPA-84363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant