Provider Demographics
NPI:1861601437
Name:MINGVIRIYA, SUKUMARN SARAH (MSHS, PA-C, ATRET)
Entity type:Individual
Prefix:MS
First Name:SUKUMARN
Middle Name:SARAH
Last Name:MINGVIRIYA
Suffix:
Gender:F
Credentials:MSHS, PA-C, ATRET
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41492 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-4533
Mailing Address - Country:US
Mailing Address - Phone:510-396-5134
Mailing Address - Fax:
Practice Address - Street 1:39400 PASEO PADRE PKWY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2310
Practice Address - Country:US
Practice Address - Phone:510-248-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NY015283363AS0400X
CA53437363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer