Individual
CHARMELENE CHANTHABOUASITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4278 W LINEBAUGH AVE, TAMPA, FL 33624-5241
(813) 977-0733
Mailing address
4278 W LINEBAUGH AVE, TAMPA, FL 33624-5241
(813) 977-0733
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA9108932
FL
Other
Enumeration date
10/02/2015
Last updated
08/01/2019
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