Basic Information
| Provider Information | |||||||||
| NPI: | 1477696284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHOMAKAY | ||||||||
| FirstName: | CHANSAMONE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 402319 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097399 | ||||||||
| FaxNumber: | 7097097053 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 KELLEY HWY | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729045024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795737990 | ||||||||
| FaxNumber: | 4795737991 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | E-6214 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200232040A | 05 | OK | MEDICAID | 178879001 | 05 | AR | MEDICAID |