Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 4301114891 | MI |
Y | 208600000X | Surgeon | 4301114891 | MI |
NPI | 1003306739 |
---|---|
Provider Name | Dr. Amy Chonghasawat |
First Address | Pontiac, MI 48341-5023 |
Second Address | Pontiac, MI 48341 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2018 |
Last Update Date | 17/05/2018 |