Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0102X | Surgical Critical Care | A143223 | CA |
N | 2086S0127X | Trauma Surgeon | A143223 | CA |
NPI | 1093004384 |
---|---|
Provider Name | Chanak Chantachote |
First Address | Northport, NY 11725 |
Second Address | Northport, NY 11725 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/04/2011 |
Last Update Date | 09/09/2020 |