Basic Information
| Provider Information | |||||||||
| NPI: | 1114031721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANCHANANAKHIN | ||||||||
| FirstName: | PHACHARAWUT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5040 WOODSPRING CT | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | GRANITE BAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 957468838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165767898 | ||||||||
| FaxNumber: | 9162850338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1712 PICASSO AVE | ||||||||
| Address2: | SUITE D | ||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956180546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165767898 | ||||||||
| FaxNumber: | 9162850338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 10/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A91630 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.