Individual provider · Type 1 NPI

Phokham Mike Sourivanh, PA-C

Medical Physician Assistant · Pensacola, FL

NPI number 1972022762 Active

Practice location

Nmrtc Pensacola 6000 West Highway 98
Pensacola, FL 32512-0001

Call (901) 874-6081 Map

Mailing address

Camp Pendleton
Apo, AP 92055

Other practice locations

  • 34800 Bob Wilson Dr, San Diego, CA 92134-1098 · (619) 532-6400
  • Camp Pendleton, Apo, AP 92055 · (760) 725-1288

Specialties and licenses

TaxonomyCodeLicense
Military Health Care Provider 171000000XNone listed
Medical Physician Assistant Primary 363AM0700XNone listed

Medical Physician Assistant: Definition to come...

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About NPI 1972022762

Phokham Mike Sourivanh, PA-C's National Provider Identifier is 1972022762, issued on Sep 13, 2017. The primary taxonomy on file is Medical Physician Assistant (363AM0700X), and the practice location is in Pensacola, FL. The record was last updated on Jun 24, 2025.