Individual
MR. PHOKHAM MIKE SOURIVANH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
NMRTC PENSACOLA 6000 WEST HIGHWAY 98, PENSACOLA, FL 32512-0001
(901) 874-6081
Mailing address
CAMP PENDLETON, APO, AP 92055
Taxonomy
Speciality
Code
Description
License number
State
171000000X
Military Health Care Provider
—
—
363AM0700X
Medical Physician Assistant
Primary
—
—
Other
Enumeration date
09/13/2017
Last updated
06/24/2025
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