Individual
DANIEL ZACKARY SOUVANNARATH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
12266 DE PAUL DR STE 310, BRIDGETON, MO 63044-2562
(314) 209-5171
Mailing address
PO BOX 955534, SAINT LOUIS, MO 63195-5534
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
2021010216
MO
363A00000X
Physician Assistant
—
—
Other
Enumeration date
05/05/2020
Last updated
09/13/2021
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