Basic Information
| Provider Information | |||||||||
| NPI: | 1164585691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAMPANE | ||||||||
| FirstName: | THOTSAPHONE | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | P.A.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3043 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605223043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307340200 | ||||||||
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| Practice Location | |||||||||
| Address1: | AURORA SINAI MEDICAL CENTER | ||||||||
| Address2: | 945 NORTH 12TH ST | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142196777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 822-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.